Wortman & Boerner Oxford Handbook of Health Psychology

The Oxford Handbook of Health Psychology
Howard S. Friedman
Print publication date: Sep 2012

Print ISBN-13: 9780195342819
Published to Oxford Handbooks Online: Sep-12
Subject: Psychology, Health Psychology
DOI: 10.1093/oxfordhb/9780195342819.001.0001
Beyond the Myths of Coping with Loss: Prevailing Assumptions Versus Scientific Evidence
Camille B. Wortman, Kathrin Boerner
DOI: 10.1093/oxfordhb/9780195342819.013.0019
Abstract and Keywords
This chapter reviews those developments in the field of bereavement that

have led to changes in prevailing views about how people cope with the loss
of a loved one. The first section provides a brief review of the most influential
theories of grief and loss. Some of these theories have contributed to the
myths of coping, whereas others have helped generate new questions about
the grieving process. The second section discusses each myth of coping,
summarizing available evidence and highlighting ways in which myths
have changed over time as research evidence has accumulated. The final
section discusses the implications of this work for researchers, clinicians,
and the bereaved themselves. In so doing, it considers the efficacy of grief
counseling or therapy. It also addresses the question of what physicians,
funeral directors, employers, and friends can do to support the bereaved in
their efforts to deal with loss.
Bereavement, grieving, grief, death, loss, coping
The death of a loved one is a ubiquitous human experience and is often

regarded as a serious threat to health and well-being. Coming to terms
with personal loss is considered to be an important part of successful adult
development (Baltes & Skrotzki, 1995). In this chapter, we draw from our
own research and that of others to explore how people are affected by the
death of a loved one. In our judgment, such losses provide an excellent
arena in which to study basic processes of stress and adaptation to change.
Unlike many stressful life experiences, bereavement cannot be altered by
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the coping efforts of survivors. Indeed, the major coping task faced by the
bereaved is to reconcile themselves to a situation that cannot be changed
and find a way to carry on with their own lives. By learning more about how
people react to a loved ones death, and how they come to terms with what
has happened, we can begin to clarify the theoretical mechanisms through
which major losses can have deleterious effects on subsequent mental and
physical health.
In our judgment, one of the most fascinating things about studying

bereavement is the extraordinary variability that has been found regarding
how people react to the death of a loved one. Some people are devastated
and never again regain their psychological equilibrium; others emerge from
the loss relatively unscathed and perhaps even strengthened (Bonanno et
al., 2002; Elison & McGonigle, 2003; Parkes & Weiss, 1983). Yet, at this point,
we know relatively little about the diverse ways that people respond to the
loss of a loved one, and why some people react with intense and prolonged
distress while others do not. Do people who have the most rewarding and
satisfying relationships with their loved one suffer the most following the
loved ones death? Or, do those with conflictual or ambivalent relationships
experience the most distress following the loss of a loved one, as clinicians
have frequently argued (see, e.g., Freud, 1917/1957; Rando, 1993; Parkes
& Weiss, 1983)? Among those who fail to show distress following the loss, is
this best understood as denial, lack of attachment, or resilience in the face of
loss?
Over the years, we carried out several systematic evaluations of common

assumptions about coping with loss that appear to be held by professionals
in the field, as well as by laypersons (Bonanno & Kaltman, 2001; Wortman
& Boerner, 2007; Wortman & Silver, 1987, 1989, 2001). We identified these
assumptions by reviewing some of the most important theoretical models
of the grieving process, such as Freuds (1917/1957) grief work perspective
and Bowlbys (1980) early attachment model (see Bonanno & Kaltman,
1999; Wortman & Silver, 2001). In addition, we examined books and articles
written by and for clinicians and other health care providers that describe the
grieving process (see, e.g., Jacobs, 1993; Malkinson, Rubin, & Witztum, 2000;
Rando, 1993; Worden, 2008). Finally, we reviewed books and articles written
by and for bereaved individuals themselves (e.g., Elison & McGonigle, 2003;
Gowell, 1992; Sanders, 1999; Umberson, 2003). The following assumptions
were identified:
Bereaved persons are expected to exhibit significant distress
following a major loss, and the failure to experience such distress is
regarded as indicative of a problem (e.g., that the bereaved person
will experience a delayed grief reaction).
Positive emotions are implicitly assumed to be absent during
this period. If they are expressed, they tend to be viewed as an
indication that people are denying or covering up their distress.
Following the loss of a loved one, the bereaved must confront and
work through his or her feelings about the loss. Efforts to avoid or
deny feelings are regarded as maladaptive in the long run.
It is important for the bereaved to relinquish his or her
attachment to the deceased loved one.
Within a year or two, the bereaved will be able to come to terms
with what has happened, recover from the loss, and resume his or
her earlier level of functioning.
Because these assumptions about the grieving process seemed to be firmly

entrenched in Western culture, we anticipated that they would be supported
by the available scientific data. However, our reviews of the literature
provided little support for any of these assumptions. For this reason, we
labeled them myths of coping with loss.
Initially, studies in the field of grief and loss were plagued by major
methodological shortcomings, including the use of convenience samples, low
response rates, attrition, and the failure to include control groups. There was
a dearth of scientific evidence on important concepts like working through
and recovery from loss. Hence, in our earliest papers discussing these
assumptions (Wortman & Silver, 1987, 1989), it was difficult to evaluate the
validity of some of them. Over the past few decades, however, research on
bereavement has burgeoned. In fact, just in the last 10 years, over 5,000
articles have appeared on grief and/or bereavement. In addition to a large
number of sound empirical studies, three editions of an influential handbook
of bereavement have appeared in the literature (Stroebe, Hansson, Schut, &
Stroebe, 2008; Stroebe, Hansson, Stroebe, & Schut, 2001; Stroebe, Stroebe,
& Hansson, 1993). As a result of the accumulation of research evidence, as
well as related theoretical developments in the field of bereavement, some
shifts have occurred in prevailing views about how people cope with the loss
of a loved one. In this chapter, we review these developments.
In the first section of the chapter, we provide a brief review of the most
influential theories of grief and loss. Some of these theories have contributed
to the myths of coping, whereas others have helped generate new questions
about the grieving process. In the second section, we discuss each myth of
coping, summarizing available evidence and highlighting ways in which the
myths have changed over time as research evidence has accumulated. In
these sections, we also identify what we believe to be the most important
new areas of research. In the final section, we discuss the implications of this
work for researchers, clinicians, and the bereaved themselves. In so doing,
we consider the efficacy of grief counseling or therapy. We also address the
question of what physicians, funeral directors, employers, and friends can do
to support the bereaved in their efforts to deal with loss.
Theories of Grief and Loss
Many different theoretical formulations have influenced the current

understanding of the grief process (for a more detailed review, see Archer,
1999, 2008; Bonanno & Kaltman, 1999; Rando, 1993; Stroebe & Schut,
2001).
Classic Psychoanalytic View
One of the most influential approaches to loss has been the classic
psychoanalytic model of bereavement, which is based on Freuds
(1917/1957) seminal paper, Mourning and Melancholia. According to Freud,
the primary task of mourning is the gradual surrender of ones psychological
attachment to the deceased. Freud believed that relinquishment of the
love object involves a painful internal struggle. The individual experiences
intense yearning for the lost loved one, yet is faced with the reality of that
persons absence. As thoughts and memories are reviewed, ties to the loved
one are gradually withdrawn. This process, which requires considerable
time and energy, was referred to by Freud as the work of mourning. At
the conclusion of the mourning period, the bereaved individual is said to
have worked through the loss and to have freed himself or herself from an
intense attachment to an unavailable person. Freud maintained that when
the process has been completed, the bereaved person regains sufficient
emotional energy to invest in new relationships and pursuits. This view of
the grieving process has dominated the bereavement literature over much
of the past century, and only more recently has been called into question
(Bonanno & Kaltman, 1999; Stroebe, 19921993; Wortman & Silver, 1989).
For example, it has been noted that the concept of grief work is overly broad
and lacks clarity because it fails to differentiate between such processes
as rumination, confrontative coping, and expression of emotion (Stroebe &
Schut, 2001).
Attachment Theory
Another theoretical framework that has been extremely influential is

Bowlbys attachment theory (Bowlby, 1969, 1973, 1980; see also Fraley &
Shaver, 1999; Shaver & Tancredy, 2001). In this work, Bowlby integrated
ideas from psychodynamic thought, from the developmental literature on
young childrens reactions to separation, and from work on the mourning
behavior of primates. Bowlby maintained that, during the course of normal
development, individuals form instinctive affectional bonds or attachments,
initially between child and parent and later between adults. He believed
that the nature of the relationship between a child and his or her mother or
caregiver has a major impact on subsequent relationships. He suggested that
when affectional bonds are threatened, powerful attachment behaviors are
activated, such as crying and angry protest. Unlike Freud, Bowlby believed
that the biological function of these behaviors is not withdrawal from the
loved one but rather reunion. However, in the case of a permanent loss, the
biological function of assuring proximity with attachment figures becomes
dysfunctional. Consequently, the bereaved person struggles between the
opposing forces of activated attachment behavior and the reality of the loved
ones absence.
Bowlby maintained that, to deal with these opposing forces, the mourner
goes through four stages of grieving: (a) initial numbness, disbelief, or
shock; (b) yearning or searching for the deceased, accompanied by anger
and protest; (c) despair and disorganization as the bereaved gives up the
search, accompanied by feelings of depression and hopelessness; and (d)
reorganization or recovery as the loss is accepted, and there is a gradual
return to former interests. By emphasizing the survival value of attachment
behavior, Bowlby was the first to give a plausible explanation for responses
such as searching or anger in grief. Bowlby was also the first to maintain
that a relationship exists between a persons attachment history and how
he or she will react to the loss of a loved one. For example, children who
endured frequent separations from their parents may form anxious and
highly dependent attachments as adults, and may react with intense and
prolonged grief when a spouse or partner dies (see Shaver & Tancredy,
2001, or Stroebe, Schut, & Stroebe, 2005a, for a more detailed discussion).
Because it provides a framework for understanding individual differences in
response to loss, Bowlbys attachment model has continued to be influential
in the study of grief and loss (see, e.g., Shear et al., 2007).
Stages Of Grief
Another aspect of Bowlbys work that has been influential in determining how
we think about grief is his idea that grieving involves stages of reaction to
loss. Drawing from this work, several theorists have proposed that people go
through stages or phases in coming to terms with loss (see, e.g., Horowitz,
1976, 1985; Ramsay & Happee, 1977; Sanders, 1989). Perhaps the most
well known of these models is the one proposed by Kbler-Ross (1969) in
her highly influential book On Death and Dying. This model, which was
developed to explain how dying persons react to their own impending death,
posits that people go through denial, anger, bargaining, depression, and
ultimately acceptance. It is Kbler-Rosss model that popularized stage
theories of bereavement. For many years, stage models have been taught
in medical, nursing, and social work schools, and in many cases, these
models are firmly entrenched among health care professionals. Kbler-Rosss
model has also appeared in articles in newspapers and magazines written for
bereaved persons and their family members. As a result, stage models have
strongly influenced the common understanding of grief in our society.
Beyond Stage Models
As research has begun to accumulate, it has become clear that there is

little support for the view that these systematic stages exist. Although
some studies purport to support stage models (Maciejewski, Zhang, Block,
& Prigerson, 2007), the weight of the evidence suggests that reactions to
loss vary considerably from person to person, and that few people pass
through the stages in the expected fashion (see Archer, 1999, or Attig,
1996, for a review). Several major weaknesses of stage models have been
identified (Neimeyer, 1998). First, they cannot account for the variability in
response that follows a major loss. Second, they place grievers in a passive
role when, in fact, grieving requires the active involvement of the survivor.
Third, such models fail to consider the social or cultural factors that influence
the process. Fourth, stage models focus too much attention on emotional
responses to the loss and not enough on cognitions and behaviors. Finally,
stage models tend to pathologize people who do not pass through the stages
As a result of these and other critiques and a lack of empirical support, most
researchers have come to believe that the idea of a fixed sequence of stages
is not particularly useful (Stroebe, Hansson et al., 2001).
More recent theoretical models, such as Neimeyers model of meaning

reconstruction (Neimeyer, 1997, 1999), have attempted to address these
shortcomings by portraying grief as a more idiosyncratic process in which
people strive to make sense of what has happened. For example, Neimeyer
(2000, 2006) has maintained that major losses challenge a persons sense of
identity and narrative coherence. Narrative disorganization can range from
relatively limited and transient to more sweeping and chronic, depending on
the nature of the relationship and the circumstances surrounding the death.
According to Neimeyer, a major task of grief involves reorganizing ones life
story to restore coherence and maintain continuity between the past and the
future.
Stress And Coping Approach
Over the past two decades, a theoretical orientation referred to as the stress
and coping approach, or the cognitive coping approach (Lazarus & Folkman,
1984; see also Chapter 8, by Carver, & Vargas, 2011, this volume), has
become highly influential in the field of bereavement. Stress and coping
theorists maintain that life changes like the death of a loved one become
distressing if a person appraises the situation as taxing or exceeding his or
her resources. An important feature of this model is that it highlights the role
of cognitive appraisal in understanding how people react to loss. A persons
appraisal, or subjective assessment of what has been lost, is hypothesized
to influence his or her emotional reaction to the stressor and the coping
strategies that are employed. As Folkman (2001) has indicated, however,
there is surprisingly little research on specific coping strategies that people
use to deal with loss and the impact of these various strategies.
To explain why a given loss has more impact on one person than another,
stress and coping researchers have focused on the identification of potential
risk factors, such as a history of mental health problems, as well as
protective factors, such as optimism or social support (For a review, see
Stroebe, Schut, & Stroebe, 2007; see also Chapter 9, by Taylor, 2011, this
volume). The appraisal of the loss, as well as the magnitude of physical and
mental health consequences that result from the loss, are thought to depend
on these factors. Those with fewer risk factors and more protective factors
are expected to recover more quickly and completely.
Toward More Comprehensive Models of Bereavement
Stage models and the stress and coping model can be applied to
bereavement, but they were not developed specifically to account for
peoples reactions to the death of a loved one. Within the past few years, two
new theoretical models have been developed: Bonannos four-component
model (Bonanno & Kaltman, 1999), and Stroebe and Schuts (1999,
2001) dual-process model. Not only do these models focus specifically
on bereavement, but each attempts to integrate elements from diverse
theoretical approaches into a comprehensive model. Bonannos goal was
to develop a conceptually sound and empirically testable framework for
understanding individual differences in grieving. He identified four primary
components of the grieving processthe context in which the loss occurs
(e.g., was it sudden or expected, timely or untimely?); the subjective
meanings associated with the loss (e.g., was the bereaved person resentful
that he or she had to care for the loved one prior to the death?); changes in
the representation of the lost loved one over time (e.g., does the bereaved
person maintain a continuing connection with the deceased?); and the role
of coping and emotion regulation processes that can mitigate or exacerbate
the stress of loss. Bonannos model makes the prediction that recovery is
most likely when negative grief-related emotions are regulated or minimized
and when positive emotions are instigated or enhanced (Bonanno, 2001).
This hypothesis, which is diametrically opposed to what would be derived
from the psychodynamic approach, has generated considerable interest and
support in recent years.
The dual-process model of coping with bereavement (Stroebe & Schut,

1999, 2001) indicates that following a loved ones death, bereaved people
alternate between two different kinds of coping: loss-oriented coping and
restoration-oriented coping. While engaged in loss-oriented coping, the
bereaved person focuses on and attempts to process or resolve some
aspect of the loss itself. Dealing with intrusive thoughts is an example
of loss-oriented coping. Restoration-oriented coping involves attempting
to adapt to or master the challenges inherent in daily life, including life
circumstances that may have changed as a result of the loss. Examples
of restoration-oriented coping include distracting oneself from the grief,
doing new things, or mastering new skills. Stroebe and Schut (2001) have
proposed that bereaved individuals alternate between loss- and restoration-
oriented coping, and that such oscillation is necessary for adaptive coping.
Restorative activities not only provide respite from the painful work of facing
the loss, but help the bereaved to replenish psychological resources, such as
energy and hope.
Stroebe and Schut (2001) have maintained that, early in the process, most
people focus primarily on loss-oriented coping but that, over time, a shift
occurs to more restoration-oriented coping. They have also indicated that
the model provides a way to understand individual differences in coping.
For example, they pointed out that considerable evidence indicates that
women tend to be more loss-oriented than men (Stroebe & Schut, 2001),
thus suggesting a possible explanation for gender differences in response
to loss. As Archer (1999) has noted, one of the most important features of
this model is that it provides an alternative to the view that grief is resolved
solely through confrontation with the loss.
More recently, Stroebe, Folkman, and colleagues proposed an integrative

risk factor framework, which incorporates an analysis of stressors, risk, and
protective factors, as well as appraisal and coping processes that are thought
to affect adjustment to bereavement (see Stroebe, Folkman, Hansson, &
Schut, 2006). The model is meant to encourage a more systematic analysis
of individual differences in response to bereavement, and, in particular
to guide research that examines interactions among the different model
components (i.e., among risk factors, appraisal, and coping processes). For
example, intrapersonal risk factors such as gender are best considered in
combination with differences in type of stressors that bereaved men and
women may face, or with differences in their stress appraisals or coping
styles.
Throughout the years, the theoretical models discussed here have influenced
and, at the same time, have been influenced by the empirical work on coping
with loss. As noted above, accumulating evidence regarding variability in
response to loss led researchers to move away from traditional grief models
and to instead employ a stress and coping framework that can account for
divergent responses to loss. In turn, the empirical evidence that has come
out of this effort to account for variability in response to loss has led to
further theoretical development. The most recent bereavement models have
drawn from these studies to develop new insights about what questions are
important to study. The following sections provide a review of the empirical
work that in some ways has been the engine behind recent changes in our
thinking about bereavement.
Revisiting the Myths Of Coping
Over the past decade, bereavement research has continued to become

more methodologically sophisticated, with many researchers employing
powerful longitudinal designs to study the impact of loss. Some longitudinal
studies have examined the reactions of the bereaved from a few months
after the loss through the first 5 years (e.g., Bonanno, Keltner, Holen, &
Horowitz, 1995; Murphy, Johnson, Chung, & Beaton, 2003; Murphy, Johnson,
& Lohan, 2002). Others have focused on people whose loved one is ill,
and have assessed relevant variables before and at various intervals after
the death (e.g., Folkman, Chesney, Collette, Boccellari, & Cooke, 1996;
Haley et al., 2008; Nolen-Hoeksema & Larson, 1999; Nolen-Hoeksema,
McBride, & Larson, 1997; Schulz, Mendelson, & Haley, 2003). Still others
have followed large community samples across time and studied those who
became bereaved during the course of the study (e.g., Bonanno et al., 2002;
Carnelley, Wortman, & Kessler, 1999; Lichtenstein, Gatz, Pederson, Berg,
& McClearn, 1996; Mendes de Leon, Kasl, & Jacobs, 1994). Most studies
have relied solely on respondents assessments of key variables such as
depression. However, some have used clinical assessments, and a few have
included nonverbal data (e.g., Bonanno & Keltner, 1997) or assessments
from others (e.g., Bonanno, Moskowitz, Papa, & Folkman, 2005).
The vast majority of bereavement studies have focused on the loss of a

spouse. In the past decade, however, important new studies have appeared
on reactions to the loss of a child (e.g., Dyregrov, Nordanger, & Dyregrov,
2003; Murphy, 1996; Murphy et al., 1999; Murphy, Johnson, & Lohan, 2003;
Wijngaards-de Mej et al., 2008); parent (e.g., Jacobs & Bovasso, 2009;
Silverman, Nickman, & Worden, 1992); and sibling (e.g., Balk, 1983; Batten
& Oltjenbruns, 1999; Cleiren, 1993; Hogan & DeSantis, 1994). In one study,
reactions to various kinds of familial loss were compared (Cleiren, 1993;
Cleiren, Diekstra, Kerkhof, & van der Wal, 1994). Most studies have focused
on respondents who are heterogeneous with respect to cause of death.
However, some have examined reactions to specific losses, such as parents
whose children experienced a sudden, traumatic death (e.g., Dyregrov et
al., 2003; Murphy, Johnson, & Lohan, 2003), or gay male caregivers whose
partners died of acquired immune deficiency syndrome (AIDS; e.g., Folkman,
1997a; Folkman et al., 1996; Moskowitz, Folkman, & Acree, 2003; Moskowitz,
Folkman, Collette, & Vittinghoff, 1996). A few studies have compared
two or more groups of respondents who lost loved ones under different
circumstances (e.g., natural causes, accident, or suicide; e.g., Cleiren,
1993; Dyregrov et al., 2003; Middleton, Raphael, Burnett, & Martinek, 1998;
Murphy, Johnson, Wu, Fan, & Lohan, 2003). Consequently, it is now possible
to determine whether the myths of coping hold true across different kinds
of deaths that occur under varying conditions.
Of course, there are still some areas where relatively little is known. For
example, the vast majority of studies on the loss of a spouse focus on
middle-aged or elderly white women. This is ironic, since the available
evidence (see, e.g., Miller & Wortman, 2002; Stroebe, Stroebe, & Schut,
2001) suggests that men are more vulnerable to the effects of conjugal loss
than are women. In recent years, there has been increasing interest in how
men grieve (see, e.g., Martin & Doka, 2000), and in gender differences in
grieving (see, e.g., Wolff & Wortman, 2006; Wortman, Wolff, & Bonanno,
2004). There are very few studies on reactions to the death of a sibling,
despite evidence that this is a profound loss, particularly for adult women
(Cleiren, 1993). With few exceptions (e.g., Carr, 2004), there is also a paucity
of studies that include blacks or Hispanics. Hence, it is difficult to determine
whether the findings reported in the literature will generalize to these or
other culturally diverse groups.
In the material that follows, each assumption about coping with loss is
discussed in some detail. As we will show, beliefs about some of these
assumptions have shifted over time as the evidence has continued to
accumulate. For example, because several studies have identified a variety
of emotional reactions among the bereaved, researchers have become more
skeptical about the assumption that most people go through a period of
intense distress following a loss. In the discussion that follows, each myth
is updated, the available evidence is presented, and gaps in our knowledge
base are identified.
The Expectation of Intense Distress
Description
Several of the most influential theories in the area, such as classic

psychoanalytic models (e.g., Freud, 1917/1957) and Bowlbys (1980)
attachment model, are based on the assumption that at some point, people
will confront the reality of their loss and go through a period of depression.
Many books written by grief researchers, as well as those written by and for
the bereaved, also convey the view that following the death of a loved one,
most people react with intense distress or depression. For example, Sanders
(1999) has maintained that once the bereaved person has accepted the
reality of the loss, he or she will go through a phase of grief that can seem
frightening because it seems so like clinical depression (p. 78). Similarly,
Shuchter (1986) has indicated that virtually everyone whose spouse dies
exhibits some signs and symptoms of depression (p. 170). It is anticipated
that depression or distress will decrease over time as the bereaved comes to
terms with the loss.
Historically, the failure to exhibit grief or distress following the loss of a
spouse has been viewed as an indication that the grieving process has
gone awry (e.g., Deutsch, 1937; Marris, 1958). Bowlby (1980) identified
prolonged absence of conscious grieving (p. 138) as one of two possible
types of disordered mourning, along with chronic mourning. Marris (1958)
has indicated that grieving is a process which must work itself out if the
process is aborted from too hasty a readjustment the bereaved may never
recover (p. 33). In recent years, some investigators have challenged the
assumption that the failure to experience distress is indicative of pathology.
For example, M. Stroebe, Hansson, and Stroebe (1993) have argued that
there are many possible reasons why a bereaved person may fail to exhibit
intense distress that would not be considered pathological (e.g., early
adjustment following an expected loss; relief that the loved one is no longer
suffering).
However, available evidence suggests that most practicing clinicians

continue to maintain, either explicitly or implicitly, that there is something
wrong with individuals who do not exhibit grief or depression following the
loss of a loved one. In a survey of expert clinicians and researchers in the
field of loss (Middleton, Moylan, Raphael, Burnett, & Martinek, 1993), a
majority (65%) endorsed the belief that absent grief exists, that it typically
stems from denial or inhibition, and that it is generally maladaptive in the
long run. An important component of this view is that it assumes that if
people fail to experience distress shortly after a loss, problems or symptoms
of distress will erupt at a later point. For example, Bowlby (1980) has argued
that individuals who have failed to mourn may suddenly, inexplicably
become acutely depressed at a later time (see also Rando, 1984; Worden,
2008). These authors have also maintained that the failure to grieve will
result in subsequent health problems (Bowlby, 1980; Worden, 2008).
Consistent with the notion that absent grief signals unhealthy denial and
repression of feelings, there is a great deal of clinical literature to suggest
that people who have lost a loved one, but who have not begun grieving,
will benefit from clinical intervention designed to help them work through
their unresolved feelings (see, e.g., Bowlby, 1980; Deutsch, 1937; Jacobs,
1993; Lazare, 1989; Rando, 1993; Worden, 2008). In a report published by
the Institute of Medicine, for example, Osterweis, Solomon, and Green (1984)
concluded that professional help may be warranted for persons who show
no evidence of having begun grieving (p. 136). Similarly, Jacobs (1993) has
suggested that the bereaved individuals who experience inhibited grief
ought to be offered brief psychotherapy by a skilled therapist (p. 246).
The failure to exhibit distress following the loss of a loved one has also been
viewed as evidence for character weakness in the survivor. In a classic
paper, Deutsch (1937) maintained that grief-related affect was sometimes
absent among individuals who were not emotionally strong enough to begin
grieving. Osterweis et al. (1984) emphasized that clinicians typically assume
that the absence of grieving phenomena following bereavement represents
some form of personality pathology (p. 18). Similarly, Horowitz (1990) has
stated that those who show little overt grief or distress following a loss are
narcissistic personalities who may be too developmentally immature
to have an adult type of relationship and so cannot exhibit an adult type
of mourning at its loss (p. 301; see also Raphael, 1983). It has also been
suggested that some people fail to exhibit distress because they were only
superficially attached to their spouses (Fraley & Shaver, 1999; Rando, 1993).
Evidence for Intense Distress
Among people who have faced the loss of a loved one, is it true that distress
is commonly experienced? Will distress or depression emerge at a later date
among those who fail to exhibit distress in the first several weeks or months
following the loss? We identified several studies that provide information
bearing on these questions. Most of these studies focused on the loss of
a spouse (Boerner, Wortman, & Bonanno, 2005; Bonanno, Moskowitz et
al., 2005; Bonanno et al., 2002; Bonanno & Field, 2001; Bonanno et al.,
1995; Bournstein, Clayton, Halikas, Maurice, & Robins, 1973; Lund et al.,
1986; Vachon, Rogers et al., 1982; Vachon, Sheldon et al., 1982; Zisook &
Shuchter, 1986); with several of these examining response to loss following
a time of caregiving for a chronically ill loved one (Aneshensel, Botticello,
& Yamamoto-Mitani, 2004; Bonanno, Moscowitz et al., 2005; Chentstova-
Dutton, et al., 2002; Li, 2005; Schulz et al., 2003; Zhang, Mitchell, Bambauer,
Jones, & Prigerson, 2008). A few studies examined reactions to the death of a
child (Bonanno, Moskowitz et al., 2005; Wortman & Silver, 1992; Wijngaards-
de Meij et al., 2008). These studies assessed depression or other forms of
distress in the early months following the death, and then again anywhere
from 13 to 60 months after the loss. The construct of depression/distress
was operationalized differently in the different studies. For example, some
studies utilized the Symptom Checklist 90 (SCL-90) depression subscale
and/or Diagnostic and Statistical Manual of Mental Disorders (DSM)-based
Structured Clinical Interview for Disorders (SCID; e.g., Bonanno, Moscowitz
et al., 2005); other studies used the Center for Epidemiologic Studies of
Depression (CESD) scale (e.g., Bonanno et al., 2002). For each study, the
investigators determined a cutoff score to classify respondents as high or low
in distress or depression.
The longitudinal studies identified here provide evidence regarding the

prevalence of different patterns of grief. Normal or common grief, which
involves moving from high distress to low distress over time, was found
among 41% of participants in a study on loss of a child from sudden infant
death syndrome (SIDS; Wortman & Silver, 1987), and anywhere between
9% and 41% in studies on conjugal loss (35% in Bonanno et al., 1995;
29% in Bournstein et al., 1973; 9% in Lund, Caserta, & Dimond, 1986;
41% in Vachon, Rogers et al., 1982; and 20% in Zisook & Shuchter, 1986).
Furthermore, in these studies, evidence for minimal or absent grief,
which involves scoring low in distress consistently over time, was found for
26% (Wortman & Silver, 1987), 41% (Bonanno et al., 1995), 57% (Bournstein
et al., 1973), 30% (Vachon, Rogers et al., 1982), 78% (Lund et al., 1986), and
65% (Zisook & Shuchter, 1986) of respondents.
In a prospective study on conjugal loss among older adults that included data
from 3 years pre-loss to 18 months post-loss (Bonanno et al., 2002; Bonanno,
Wortman, & Nesse, 2004), nearly half of the participants (46%) experienced
low levels of distress consistently over time and were labelled resilient.
Only 11% showed normal or common grief. Another trajectory in this
study referred to as depressed-improved reflected elevated distress before
the loss and improvement after the loss (10%). A similar pattern of reduced
distress levels following the loss was detected in prospective studies that
included both pre- and post-loss data on caregivers of dementia patients
(Aneshensel et al., 2004; Schulz et al., 2003; Zhang et al., 2008), as well as
on caregiver samples that included a variety of illnesses (Li, 2005). In two of
these studies (Aneshensel et al., 2004; Zhang et al., 2008), only about 17%
showed a pattern of distress reflecting common grief following the death.
Moreover, Aneshensel and colleagues observed a pattern of stable but low
distress (64%) and absent distress (11%) in a majority of their participants,
and Zhang and colleagues found persistently absent depression in about half
of their sample.
Taken together, in all studies, less than half of the sample showed normal
grief, and in many, such a reaction was shown by only a small minority of
respondents. In fact, in the prospective study on conjugal loss by Bonanno
et al. (2002), the relatively small proportion of those who showed normal
grief (11%) was almost equal to those who showed a depressed-improved
pattern of being more distressed before the loss, followed by improvement
after the loss (10%). Most important, however, the available evidence shows
that minimal or absent grief is very common. The number of respondents
failing to show elevated distress or depression at the initial or final time point
was sizable, ranging from one-quarter of the sample to more than three-
quarters of the sample. In fact, a comparison of nonbereaved and bereaved
individuals (who lost either a child or a spouse; Bonanno, Moskowitz et
al., 2005) showed that, in terms of distress levels, slightly more than half
of the bereaved did not significantly differ from the matched sample of
nonbereaved individuals when assessed at 4 and 18 months post-loss.
It should be noted that category labels such minimal or absent grief do

not mean that there was absolutely no distress at any moment after the loss,
but rather that, despite brief spikes in distress around the time of the death
(Bonanno, Moskowitz et al., 2005) or a short period of daily variability in
levels of well-being (Bisconti, Bergeman, & Boker, 2004), people who showed
these patterns had generally low distress levels and managed to function at
or near their normal levels (Bonanno, 2005). The prevalence of the minimal
or absent grief reaction alone calls into question the assumption that
failure to show distress following a loss is pathological. In fact, it suggests
that learning more about why many people do not exhibit significant distress
following a loss should become an important research priority.
Studies With Assessment of Mild Depression
When we have described these findings in the past (e.g., Bonanno et al.,
2002; Wortman & Silver, 1989, 2001), it was sometimes suggested that the
data may underestimate those who show significant distress following a
loss. This is because most of the studies we reviewed classify respondents
as depressed only if their score exceeds a cutoff believed to reflect clinically
significant levels of depression. Respondents who do not exhibit major
depression may still be evidencing considerable distress or depression.
The previous studies do not speak to this issue, since they do not include
measures of mild depression.
Fortunately, such measures have been included in a number of studies. For

example, Bruce, Kim, Leaf, and Jacobs (1990) assessed dysphoria as well
as depression in a study of conjugally bereaved individuals (aged 45 and
older). Dysphoria was defined as feeling sad, blue, depressed, or when you
lost all interest and pleasure in things you usually cared about or enjoyed
for 2 weeks or more. About 60% of the respondents had experienced
dysphoria. However, a significant minority (almost 40%) did not go through
even a 2-week period of sadness following their loss. Similarly, Zisook,
Paulus, Shuchter, and Judd (1997) conducted a study of elderly widowers
and widows in which their ratings on symptom inventories were used to
classify them into DSM-IV categories of major depression, minor depression,
subsyndromal depression (endorsing any two symptoms from the symptom
list), and no depression (endorsing one or no items reflecting depression).
Two months after the partners death, 20% were classified as showing major
depression, 20% were classified as exhibiting minor depression, and 11%
were classified as evidencing subsyndromal depression. Forty-nine percent
of the respondents were classified as evidencing no depression (for similar
results, see Cleiren, 1993). These studies provide compelling evidence that,
following the death of a spouse, a substantial percentage of people do not
show significant distress.
Delayed Grief
Is it true that if the bereaved do not become depressed following a major

loss, a delayed grief reaction, or physical health problems, will emerge
at some point in the future? The data from the longitudinal studies we
identified fail to support this view. In two studies, there were no respondents
showing a delayed grief reaction (Bonanno et al., 1995; Bonanno & Field,
2001; Zisook & Shuchter, 1986). In the remaining studies, the percentage
of respondents showing delayed grief was .02%, 1%, 2%, 2.5%, and 5.1%,
respectively (Boerner et al., 2005; Bournstein et al., 1973; Lund et al., 1986;
Wortman & Silver, 1987; Vachon, Rogers et al., 1982). It should be noted
that in two of these studies (Lund et al., 1986; Zisook & Shuchter, 1986),
bereaved respondents were interviewed at frequent intervals during the
course of the study. There were very few respondents who moved from low
distress to high distress on any subsequent interview. These studies indicate
that delayed grief does not occur in more than a small percentage of
cases. Nor do physical symptoms appear to emerge among those who fail
to experience distress soon after the loss. Both the Boerner et al. (2005)
and Bonanno and Field (2001) studies are convincing on this point, because
conjugally bereaved individuals were assessed over a 4- and 5-year period,
respectively, using multiple outcome measures. Data failing to support the
delayed grief hypothesis were also obtained by Middleton et al. (1996).
Based on cluster analyses of several bereaved samples, she concluded that
no evidence was found for delayed grief. Nonetheless, in the previously
described survey conducted by Middleton et al. (1993), a substantial majority
of researchers and clinicians (76.6%) indicated that delayed grief does occur.
Predictors of Minimal Distress
The hypothesis that some people fail to become distressed following a loss
because they were not attached to the loved one, or because they were cold
and unfeeling, has only recently been subject to empirical research. Bonanno
et al. (2002) tested the prediction that those who reported low levels of
depression from pre-loss through 18 months of bereavement (resilient
group) would score higher on pre-loss measures of avoidant/dismissive
attachment than those in other groups (depressed-improved, common grief,
chronic grief, and chronic depression). They also examined whether those
in the resilient group would evaluate their marriage less positively and
more negatively, and whether they would be rated by interviewers as less
comfortable and skillful socially, and as exhibiting less warmth compared
with the other groups at the pre-loss time point. The resilient group did not
appear to differ from the other groups on any of these variables. A follow-
up study yielded similar results with respect to variables on processing
the loss (Bonanno et al., 2004). For example, the resilient group scored
relatively high on comfort from positive memories of the deceased, a finding
that also argues against the view that they were not strongly attached to
the deceased. Furthermore, in their study on the loss of spouse or child,
Bonanno, Moskowitz, et al. (2005) found that the friends of bereaved
participants who showed resilience following the death rated them more
positively, and reported having more contact and closer relations with
them. Taken together, these findings do not supportand even contradict
the hypothesis that the absence of intense distress following loss is a
sign of lack of attachment to the deceased or the inability to maintain close
relationships.
Thus, available evidence clearly indicates that the so-called normal

grief pattern is not as common as was assumed in the past, and that a
significant proportion of bereaved individuals experience relatively little
distress following a loss, without showing delayed grief or other signs of
maladjustment. It should be noted, however, that such a reaction is far more
prevalent following some kinds of losses than others. For example, elderly
people who lose a spouse are more likely to show consistently low distress
than are younger individuals who lose a spouse or parents who lose a child.
In fact, research on the loss of a child under sudden or violent circumstances
suggests that it is normative to experience intense distress following such
a loss. In her study of the violent death of a child, for example, Murphy
(1996) found that 4 months after the loss, more than 80% of the mothers
and 60% of the fathers rated themselves as highly distressed. Thus, there
is clear evidence that both the nature of the death and the circumstances
surrounding the loss play a critical role in peoples response to loss. These
and other factors associated with long-term difficulties in adaptation to loss
will be discussed in the section on recovery.
Future Directions
Given the prevalence of resilience or low distress following a loss, we need

to learn more about the potential costs and benefits of this response. As
described previously, there is evidence that, for the bereaved person,
resilience, or showing consistently low distress following the loss, appears
to be an adaptive response. However, it would be interesting to address
whether any disadvantages are associated with resilience. For example,
there could be negative social implications of a resilient pattern in response
to bereavement. In some cases, the resilient person may elicit negative
reactions from others because others expect the bereaved to show more
distress. Others may interpret low levels of distress as an indication of
aloofness or indifference. In other cases, showing resilience may reflect
positively on the bereaved because it is easier for others to be with a less-
distressed person. Another intriguing question is what happens in families
or other social groups when one person shows a low distress pattern after a
loss, whereas the other members in this social system experience intense
distress. In such a case, would those who are more distressed be likely to
benefit from the presence or availability of a resilient person? Or, would the
lack of congruence in the experience of individual members be more likely
to lead to misunderstandings and individual coping efforts that interfere with
one another? These questions are likely to assume considerable importance
in couples following the death of a child. For example, one spouse may feel
uncomfortable expressing feelings of distress about the loss if it appears
that the partner is not as distressed (e.g., Wortman, Battle, & Lemkau,
1997). Future work addressing these questions would make an important
contribution because people rarely face a loss in a social vacuum.
Positive Emotions Are Typically Absent
Description
The most influential theories of grief and loss, such as Freuds (1917/1957)
psychoanalytic model and Bowlbys (1980) attachment model, emphasize
the importance of working through the emotional pain associated with the
loss. Amid the despair and anguish that often accompany grief, positive
emotions may seem unwarranted, even inappropriate (Fredrickson, Tugade,
Waugh, & Larkin, 2003). When they are mentioned at all, positive emotions
are typically viewed as indicative of denial and as an impediment to the
grieving process (Deutsch, 1937; Sanders, 1993; see Keltner & Bonanno,
1997, for a review). With notable exceptions (e.g., Folkman, 1997b, 2008;
Folkman & Moskowitz, 2000; Fredrickson, 2001; Lazarus, Kanner, & Folkman,
1980), theories focusing specifically on the grieving process, or more
generally on coping with adversity, have failed to consider the role that may
be played by positive emotions.
In the 1980s, Wortman and her associates became interested in whether

positive emotions were experienced by people who had encountered major
losses, and if so, whether they could perhaps sustain hope and facilitate
adjustment. Therefore, they decided to measure positive as well as negative
emotions in two studies, one focusing on permanent paralysis following a
spinal cord injury, and one focusing on loss of a child as a result of SIDS; see
Wortman and Silver (1987) for a more detailed discussion. In conducting
the first study, they encountered extreme resistance from the hospital staff,
who felt it was ridiculous to ask people who were permanently disabled
about their positive emotions. In the second study, they experienced similar
problems from their interviewers, who did not want to ask people who had
lost a child how many times they had felt happy in the past week. Only
through careful pilot work and much persuading were they able to convince
the staff, and the interviewers, that the project was indeed feasible and
worthwhile.
Evidence for Positive Emotions Following Loss
Both of these studies provided evidence that positive emotions are quite
prevalent following major loss. At 3 weeks following the death of their
infant to SIDS, parents reported experiencing positive emotions such as
happiness as frequently as they experienced negative feelings. By the
second interview, conducted 3 months after the infants death, positive
affect was more prevalent than negative affect, and this continued to be
the case at the third interview, conducted at 18 months after the loss.
Respondents were asked to describe the intensity as well as the frequency
of their feelings. These measures were included so that the investigators
could determine whether negative feelings, although no more prevalent than
positive ones, were more intense. However, this did not turn out to be the
case. At all three interviews, feelings of happiness were found to be just as
intense as feelings of sad ness. In fact, at the second and third interviews,
respondents reported that their feelings of happiness were significantly more
intense than their feelings of sadness.
Subsequent studies have corroborated that positive emotions are surprisingly

prevalent during bereavement. For example, when caregivers of men
who died of AIDS were asked to talk about their experiences, about 80%
evidenced positive emotions during the conversation, whereas only 61%
conveyed negative emotions (Folkman, 1997a, 2001; Folkman & Moskowitz,
2000; Stein, Folkman, Trabasso, & Christopher-Richards, 1997). Except for
just before and just after the death, caregivers reports regarding positive
states of mind were as high as community samples (Folkman, 1997a).
Bonanno, Moskowitz, et al., examined positive affect scores of caregivers
from eight months preloss to 8 months postloss. They demonstrated that
the presence of positive emotions even within a few weeks before and after
the death. Comparable findings have been obtained from a study that went
beyond self-report data. At 6 months post-loss, Bonanno and Keltner (1997)
coded facial expressions of conjugally bereaved respondents while they
were talking about their relationship with the deceased. Videotapes of the
interviews were then coded for the presence of genuine or Duchenne
laughs or smiles, which involve movements in the muscles around the eyes.
Positive emotion was exhibited by the majority of participants. Moreover,
the presence of positive affect was associated with reduced grief at 14 and
25 months post-loss. Those who exhibited Duchenne laughs or smiles also
evoked more favorable responses in observers (Keltner & Bonanno, 1997).
In addition to rating them more positively overall, observers rated those who
engaged in laughs and smiles as healthier, better adjusted, less frustrating,
and more amusing. These findings suggest that one way positive emotions
may facilitate coping with loss is by eliciting positive responses from those in
the social environment.
Revised Stress and Coping Model
Drawing on her research on caregivers of men who died of AIDS, Folkman

(1997b) concluded that it is important to learn more about how positive
psychological states are generated and maintained during a major loss, as
well as how they help to sustain coping efforts. In her revision of Lazarus
and Folkmans original model of the coping process (1984), Folkman
(1997b, 2001, 2008) has proposed that, when people are distressed as
a result of a loss event, they can generate positive emotions by infusing
ordinary events with positive meaning. This observation came about in
an interesting way. In her study of caregiving partners of men with AIDS,
Folkman (1997a) had initially focused exclusively on stressful aspects
of the caregiving situation. Respondents were questioned about these
aspects every 2 months. Shortly after the study began, several participants
reported that we were missing an important part of their experience by
asking only about stressful events; they said we needed to ask about positive
events as well if we were to understand how they coped with the stress of
caregiving (p. 1215). Consequently, Folkman added a question in which
respondents were asked to describe something you did, or something
that happened to you, that made you feel good and that was meaningful
to you and helped you get through the day (p. 1215). Such events were
reported by 99.5% of the respondents. Events focused on many different
aspects of daily life, such as enjoying a good meal, receiving appreciation
for something done for ones partner, or going to the movies with friends.
Folkman has hypothesized that events of this sort generate positive emotion
by helping people feel connected and cared about, by providing a sense of
achievement and self-esteem, and by providing a respite or distraction from
the stress of caregiving. She has suggested that engaging in activities that
generate positive emotions, and positive emotions themselves, are likely
to help sustain coping efforts in dealing with a stressful situation. Recent
empirical evidence is consistent with this prediction. Positive affect is not
only quite prevalent at times of adversity but also appears to ameliorate
bereavement-related distress (Bonanno, Moskowitz et al., 2005; Moskowitz
et al., 2003). For example, in a study on the role of daily positive emotions
during bereavement, Ong, Bergeman, and Bisconti (2004) found that the
stressdepression correlation was significantly reduced on days in which
more positive emotion was experienced.
Broaden-And-Build Theory of Positive Emotions
Another theory that has important implications for understanding the role
that positive emotions may play in coping with loss is Fredricksons broaden-
and-build theory of positive emotions (Fredrickson, 1998, 2001; Fredrickson
& Losada, 2005; Fredrickson et al., 2003). Fredrickson has maintained that
positive emotions can broaden peoples attention, thinking, and behavioral
repertoire, bringing about an increase in flexibility, creativity, and efficiency
and thereby improving their ways of coping with stress. She maintains
that, over time, this helps people to accumulate important resources,
including physical resources (e.g., health), social resources (e.g., friendships),
intellectual resources (e.g., expert knowledge), and psychological resources
(e.g., optimism). In brief, her work suggests that efforts to cultivate positive
emotions in the aftermath of a stressful life experience will pay off in
the short run by improving the persons subjective experience, undoing
physiological arousal, and enhancing coping, and in the long term by building
enduring resources.
Future Directions
In subsequent work, it will be important to learn more about how people

cultivate and maintain positive emotions in the midst of coping with a
major loss. Are there particular strategies that people use to generate and
maintain such emotions during a crisis? Are those with certain personality
characteristics or belief systems (e.g., those with particular spiritual beliefs)
more likely than others to experience positive emotions in the context
of adversity? We also need to know more about the impact of positive
emotions on adaptation to a major life event such as bereavement. Specific
hypotheses could be derived from the Frederickson model, addressing the
mechanisms through which positive emotions are thought to improve coping
with stress. For example, one could assess whether those who experience
positive emotions following a loss indeed show higher flexibility, creativity,
and efficiency in terms of their thinking and coping behavior, and if so,
whether this buffers the negative impact of the loss on peoples adjustment.
As Folkman (1997b) has pointed out, it would also be useful to determine
whether positive psychological states must reach a certain level of intensity
or duration in order to sustain or facilitate coping with loss. Future work in
this area is particularly important because strategies that help generate
positive emotions in the face of loss are a concrete tool that can be taught
as part of an intervention (cf. Fredrickson, 2001). It will also be important to
learn more about difficulties the bereaved may encounter in experiencing or
expressing positive emotions following a loss. For example, some people may
feel guilty if they enjoy something because their loved one is missing out
on enjoyable experiences. Experiencing or expressing positive emotions may
also make people feel that they are being disloyal toward their loved one.
The Importance of Working Through the Loss
Description
Among researchers as well as practitioners in the field of grief and loss,

it has been commonly assumed that to adjust successfully to the death
of a loved one, a person must work through the thoughts, memories,
and emotions associated with the loss. The term grief work was originally
coined by Freud (1917/1957), who maintained that working through our
grief is critically importanta process we neglect at our peril. Although
there is some debate about what it means to work through a loss, most
grief theorists assert that it involves an active, ongoing effort to come to
terms with the death. Implicit in our understanding of grief work is that
it is not possible to resolve a loss without it. As Rando (1984) has stated,
For the griever who has not attended to his grief, the pain is as acute and
fresh ten years later as it was the day after (p. 114). Attempts to deny the
implications of the loss, or block feelings or thoughts about it, are generally
regarded as maladaptive. As noted earlier, this view of the grieving process
has constituted the dominant perspective on bereavement for the past
half century (Bonanno, 2001). It is only within the past several years that
investigators have begun to question these ideas (see, e.g., Bonanno &
Kaltman, 1999; Stroebe, 19921993; Wortman & Silver, 1989, 2001).
However, an examination of the most influential books on grief therapy

suggests that clinicians still regard working through as a cornerstone of
good treatment (see, e.g., Rando, 1993; Worden, 2008). Consequently,
a major treatment goal for clinicians typically involves facilitating the
expression of feelings and thoughts surrounding the loss (see Bonanno,
2001, for a more detailed discussion). Clinicians have also emphasized the
importance of expressing negative feelings that are directed toward the
deceased, such as anger or hostility (see, e.g., Lazare, 1989; Raphael, 1983).
In fact, practitioners have frequently argued against the use of sedative
drugs in the early phases of mourning because they may interfere with
the process of working through the loss (see Jacobs, 1993, for a more
detailed discussion). As Jacobs (1993) has indicated, such attitudes are
prevalent among practicing clinicians despite the fact that there is little or
no evidence for the idea (p. 254).
Evidence on The Value Of Working Through
Over the past decade, several studies relevant to the construct of working
through have appeared in the literature. These studies have assessed such
constructs as confronting thoughts and reminders of the loss versus avoiding
reminders and using distraction (e.g., Bonanno et al., 1995; Bonanno &
Field, 2001; M. Stroebe & Stroebe, 1991), thinking about ones relationship
with the loved one (e.g., Nolen-Hoeksema et al., 1997), verbally expressing
or disclosing feelings of grief or distress (e.g., Lepore, Silver, Wortman,
& Wayment, 1996), exhibiting negative facial expressions (e.g., Bonanno
& Keltner, 1997; Keltner & Bonanno, 1997), or expressing ones feelings
through writing about the loss (Lepore & Smyth, 2002; Pennebaker, Zech, &
Rime, 2001; Smyth & Greenberg, 2000). These studies have provided limited
support for the notion that working through is important for adjustment
to the death of a loved one. Some have found support for the grief work
hypothesis on only a few dependent measures, some have not found any
support for this hypothesis, and some have reported findings that directly
contradict this hypothesis.
Confronting Versus Avoiding Loss
In one of the earliest studies on grief work, M. Stroebe and Stroebe (1991)
assessed five kinds of behaviors associated with confronting the loss of
ones spouse (e.g., disclosed ones feelings to others) or with avoidance
(e.g., avoided reminders), at 4 to 7 months, 14 months, and 2 years post-
loss. At the final time point, there were no differences between widows who
had showed evidence for confronting their loss at either of the first two
time points and those who did not. However, different findings emerged
for widowers. The less frequently they used avoidance as a coping strategy
at prior time points, the greater was their improvement in depression
scores at the final time point. Overall, these results provide limited support
for the grief work hypothesis, leading M. Stroebe and Stroebe (1991) to
conclude that the statement Everyone needs to do grief work is an
oversimplification (p. 481).
In a study of gay men who lost a partner to AIDS, Nolen-Hoeksema and

colleagues (1997) examined the impact of thinking about ones relationship
with the partner versus avoiding such thoughts. Those who had thought
about their life without their partner, and how they had changed as a result
of the loss, showed more positive morale shortly after the death than those
who did not. However, this group showed more depression over the 12
months following the loss.
In another study comparing those who used avoidant versus more

confrontative coping styles (Bonanno et al., 1995; Bonanno & Field,
2001), respondents who had lost a spouse were asked to talk about their
relationship to the deceased, and their feelings about the loss, at the 6-
month point following their loss. Physiological data assessing cardiovascular
reactivity were also collected. Respondents who evidenced emotional
avoidance (i.e., little emotion relative to their physiological reactivity)
showed low levels of interviewer-rated grief throughout the 2-year study.
Among respondents who initially showed emotional avoidance, there was
no evidence of delayed grief. Although respondents with an avoidant style
did show higher levels of somatic complaints at 6 months post-loss, these
symptoms did not persist beyond the 6-month assessment and were not
related to medical visits. Even stronger evidence for the adaptive benefits
of emotional avoidance, also termed repressive coping comes from a
recent study of bereaved individuals who lost a spouse or parent (Coifman,
Bonanno, Ray, & Gross, 2007). Emotional avoidance predicted fewer
psychological symptoms and somatic complaints, a less significant medical
history, and ratings of better adjustment from friends, both concurrently
and over time (up to 18 months post-loss). No health costs of emotional
avoidance were detected at any point in this study.
Taken together, the results of these studies indicate that, under some
circumstances, confrontative coping is beneficial whereas, under other
circumstances, it has no effect or has a detrimental impact on adjustment.
In these studies, many respondents did not make an active, ongoing effort
to confront the loss but nonetheless evidenced good adjustment following
bereavement. Apparently, focusing attention away from ones emotional
distress can be an effective means of coping with the loss of a loved one.
Talking About Negative Feelings
A study by Bonanno and Keltner (1997) casts doubt on the value of

expressing negative feelings. These investigators assessed the expression
of negative emotion in two ways: through self-report and through facial
expressions. An advantage of studying facial expressions is that they can
be assessed independently of self-report and even without participant
awareness. Those who expressed negative feelings or manifested negative
facial expressions while talking about the decreased 6 months post- loss
showed higher interviewer-rated grief at 14 months post-loss. This was
particularly the case for facial expressions of anger, the emotion most
consistently believed by grief work theorists to require expression (Belitsky &
Jacobs, 1986).
As Bonanno (2001) has indicated, it was not clear from this study whether
the expression of negative emotions actually influenced subsequent grief,
or whether individuals in a more acute state of grief merely tended to
express more negative emotionsin other words, the expression of negative
affect may have simply been a by-product of grief. To address this concern,
Bonanno (2001) reanalyzed the facial expression data controlling for the
initial level of grief and distress, which enabled him to isolate the extent to
which expressing negative emotion was related to subsequent grief. Even
under these stringent conditions, facial expressions of negative emotion
were still related to increased grief at 14 months post-loss. These studies
by Bonanno and his associates suggest that minimizing the expression
of negative emotion results in reduced grief over time, which is just the
opposite of what the grief work hypothesis would predict.
Writing About Negative Feelings
Pennebaker et al. (2001) agreed with Bonanno that results of prior studies
were difficult to interpret because current distress is the best predictor of
future distress, and high initial distress may merely be a reflection on grief.
To provide a more convincing test of the value of expressing ones distress,
Pennebaker and his associates developed an intervention that involved
expression of emotion by writing about the trauma or loss. Participants are
asked to write essays expressing their deepest thoughts and feelings about
the most traumatic event they can remember. Control participants are asked
to write about innocuous topics, such as their plans for the day. Typically,
participants write for 2030 minutes on several consecutive days (see, e.g.,
Pennebaker & Beall, 1986). When given these instructions, people are indeed
willing to write about experiences that are very traumatic and upsetting.
According to Pennebaker et al. (2001), Deaths, abuse incidents, and tragic
failures are common themes (p. 530).
It has been shown that writing has a positive impact on health outcomes
such as health center visits and immunologic status. The literature on
the impact of writing on mood and psychological well-being is somewhat
mixed (see Pennebaker et al., 2001, for a review; see also Chapter 18,
by Pennebaker, & Chung, 2011, this volume). However, a meta-analysis
suggests that overall, mood and psychological well-being being improve
following writing. The results also indicate that writing can affect health
outcomes as well as behavioral changes, such as an improvement in
grades, or the ability to get a new job after being laid off. Hence, the results
illustrate that the impact of writing is not restricted to any one outcome.
Smyths (1998) study suggested that the respondents who completed
the writing task showed significant improvements in several domains.
Specifically, they scored higher on reported physical health, psychological
well-being, physiology functioning, and general functioning. The effect
sizes that emerged in this study were similar in magnitude to those of other
psychological interventions.
Do these writing effects apply to individuals who have lost a loved one?
Pennebaker et al. (2001) have estimated that, across the studies conducted
in his lab, approximately 20% of participants write about the death of a
close friend or family member. According to these investigators, people
who write about death benefit as much as people who write about other
topics. However, studies focusing on the value of emotional expression
among the bereaved have produced inconclusive findings (see M. Stroebe,
Stroebe, Schut, Zech, & van den Bout, 2002, for a review). For example,
Segal, Bogaards, Becker, and Chatman (1999) conducted a study with
elderly people who had lost a spouse an average of 16 months previously.
Respondents were instructed to talk into a tape recorder about the loss and
to express their deepest feelings. When compared with a delayed treatment
control condition, those who expressed their feelings showed a slight but
nonsignificant improvement in hopelessness. No significant effects emerged
on other measures of distress, such as depression and intrusion/avoidance.
Two studies by Range and her associates (Kovac & Range, 2000; Range,
Kovac, & Marion, 2000) also fail to support the value of written emotional
expression among the bereaved. In the first study (Range et al., 2000),
undergraduates who had experienced the loss of a friend or family member
as a result of an accident or a homicide were asked to write about their
deepest thoughts and feelings surrounding the death. A control group was
asked to write about a trivial issue. The results revealed that both groups
showed improvements in symptoms of depression, anxiety, and grief during
the course of the study. There was no indication of greater improvement
among respondents who were assigned to express their feelings. There were
also no differ ences among the two groups in doctor visits. In the second
study, people who had lost a loved one to suicide were invited to express
their deepest feelings or to write about a trivial issue. The study included
many dependent measures such as intrusion/avoidance, doctors visits, and
grief. On the majority of measures, there were no differences between the
groups. Similar results were also obtained in an intervention study by Bower,
Kemeny, Taylor, and Fahey (2003). Women who had lost a close relative to
breast cancer were assigned to write about the death or about neutral topics.
Writing did not appear to facilitate adaptation to the loss.
Stroebe et al. (2002) conducted two exceptionally well-designed studies to

determine whether expression of emotions facilitates recovery among the
bereaved. In the first study, the authors focused on disclosures of emotion
made by the bereaved in everyday life. A large sample of people who had
lost a spouse were asked to complete a questionnaire designed to assess
disclosure of emotion to others at four points over a 2-year period. The
results provided no evidence that disclosure facilitated adjustment to loss.
In the second study, people who lost a spouse from 4 to 8 months previously
were randomly assigned to one of three writing conditions or to a no-writing
control condition. Participants in the first writing condition were instructed
to focus on their emotions. Those in the second condition were told to focus
on problems and difficulties they have to deal with as a result of the death.
The final group was asked to focus on both their feelings and problems. The
results of this study provided no evidence whatsoever for a general beneficial
effect of emotional expression. None of the experimental groups was better
off than control respondents on any measures.
To determine whether the emotional expression of grief may be beneficial

under specific conditions, M. Stroebe et al. (2002) further examined
whether writing effects were a function of the type of loss. When they
compared bereaved participants who expected the loss with those who
had encountered a sudden, unexpected loss, there was no indication that
emotional expression through writing was more beneficial for the latter
group. They also investigated whether the expression of emotions may work
only among people who have not yet had much opportunity to disclose their
feelings. However, they found no evidence to suggest that those who had
rarely disclosed their feelings in the past benefited more from the writing
intervention than those who had disclosed their feelings more frequently. In
fact, these investigators found that low disclosers were less likely to suffer
from intrusive thoughts, and had fewer doctor visits, than did high disclosers.
Similar findings were obtained by Seery, Silver, Holman, Ence, and Chu
(2007) in a study of the impact of expressive thoughts following the
September 11, 2001 catastrophe. Members of a large, representative sample
were given the opportunity to express their feelings about the terrorist
attacks of September 11, 2001 on that day and the following few days.
Follow-up surveys were conducted to assess mental and physical health
outcomes over the next 2 years. Contrary to expectation, participants who
chose not to express any initial reactions to the attacks reported better
outcomes over time than did those who expressed feelings about the
attacks. Among respondents who chose to express their reactions at the
time of the attacks, longer responses were associated with worse outcomes
over time. These results suggest that rather than indicating pathology,
reluctance to express negative feelings appears to reflect resilience in the
face of trauma.
Grief Work, Avoidance, and Rumination
Bonanno, Papa, Lalande, Zhang, and Noll (2005) conducted a study on grief
processing and deliberate grief avoidance among bereaved spouses and
parents in two cultures: the United States and the Peoples Republic of China.
These investigators tested different versions of the grief work hypothesis,
using a comprehensive measure of grief processing that included thinking
and talking about the deceased, having positive memories, expressing
feelings, and searching for meaning. They also developed a measure of
grief avoidance that included avoidance of thinking, talking, and expressing
feelings about the deceased. This study addressed (a) the traditional
hypothesis that grief processing was a necessary step toward positive
adjustment, and that the absence of grief processing reflects avoidance or
denial; (b) the conditional hypothesis that grief work may be beneficial for
those with severe grief; and (c) another modified hypothesis that grief work
was more akin to rumination, with the prediction that those who scored high
on grief processing initially would continue to score high on this measure and
show poorer adjustment at the 18-month follow-up than those who did not
score high on initial grief processing.
Support was found for the third but not for the first two hypotheses. Grief
processing and avoidance each predicted poorer adjustment for U.S.
participants, even for those who had shown more severe grief initially. The
authors interpreted this as contra dictory to both the traditional and the
conditional grief work hypothesis but as consistent with the grief work as
rumination hypothesis. Grief processing and avoidance did not emerge as
significant predictors of outcome among the Chinese participants, which
may have reflected cultural differences in terms of mourning rituals and
practices. Overall, the authors concluded that these findings cast doubt on
the usefulness of grief processing and argued that it may be inadvisable to
encourage the bereaved to focus on processing the loss.
When reviewing the different studies that have tested the grief
work hypothesis, it is important to keep in mind how grief work was
conceptualized in each study, and how this may have affected the findings.
For example, it is possible that Bonanno, Papa, et al. (2005) failed to find
positive effects of grief processing because their grief processing measure
included the expression of feelings, which, as discussed previously, has
been found to predict worse outcome in some studies, and searching for
meaning, which may be regarded as reflective of ruminative thinking. There
is evidence that rumination, if defined as engaging in thoughts and behaviors
that maintain ones focus on negative emotions (Nolen-Hoeksema, 1991),
heightens distress, interferes with problem solving, and may drive away
potential supporters.
More recently, it has been argued that rumination represents a form of

avoidance and that it should be distinguished from other efforts to confront
the reality of the death, such as finding meaning in loss or making plans
for ones life beyond the loss. The idea is that rumination tends to involves
a deliberate pondering on a narrow aspect of the loss (e.g., the event
leading up to it and what one could have done to prevent it), a focus that
prevents the person from facing up to the reality of the loss (Stroebe
et al., 2007; p. 470). This reconceptualization of rumination as avoidance
is in line with findings by Boelen and colleagues that rumination (e.g.,
thinking about who is to blame for the death) and behavioral avoidance
(avoiding places that remind of the deceased) items loaded on a single factor
(Boehlen, van den Bout, & van den Hout, 2006). This finding and the related
conceptual discussion of the nature of rumination underscore the importance
of identifying the content and focus of thoughts and actions pertaining to
the loss, rather than relying on simple contrasting of broad concepts such as
confrontation and avoidance.
Future Directions
In future work, it will be important to include separate assessments of

constructs pertaining to working through, such as thinking about the loss,
talking about what has happened, crying, or searching for meaning. This
would help to clarify how these constructs are related to one another and to
identify the role played by each in the process of recovery. When comparing
findings from different studies on this issue, and in particular when drawing
conclusions about adaptiveness, it is extremely important to be clear about
what kind of grief processing is talked about in each specific case. This also
leads to the more general question regarding what kind of grief processing
may be beneficial for whom, and under which circumstances. For example,
one reason the literature on working through may be so inconsistent is
because some studies may have included people who did not need to work
through what happened, some who may have been reluctant to engage
fully in the process, and some who were made worse by being required
to confront the trauma. Those who may have difficulty expressing their
emotions may benefit the most from interventions such as writing about their
experience (Lumley, Tojeck, & Macklem, 2002; Norman, Lumley, Dooley, &
Diamond, 2004). Furthermore, it is possible that working through may be
more beneficial for certain kinds of events, such as those that are particularly
traumatic and/or likely to shatter the survivors views of the world. We also
need to know more about the conditions under which emotional expression
reduces the bereaved persons distress, helps him or her to gain insight or
cognitively structure what has happened, and helps to elicit support and
encouragement from others. Hopefully, subsequent research will assist us in
specifying the conditions under which working through ones loss is more
or less likely to be beneficial, and if it is indicated, how this grief processing
needs to be done to truly facilitate recovery and adjustment.
Breaking Down Attachments
Description
According to the traditional view on grief, espoused by Freud (1917/1957)

and other psychoanalytic writers (e.g., Volkan, 1971), it is necessary to
disengage from the deceased in order to get on with life. These writers
believed that, for grief work to be completed, the bereaved person must
withdraw energy from the deceased and thus free him- or herself from
attachment to an unavailable person. This view remained influential for
many years, with its advocates maintaining that if attachments are not
broken down, the bereaved will be unable to invest his or her energy in
new relationships or activities. It is generally believed that bereaved people
accomplish this task by carefully reviewing thoughts and memories of the
deceased, as well as both positive and negative aspects of the relationship
(see, e.g., Rando, 1993; Raphael, 1983). Clinicians have traditionally
maintained that the failure to break down bonds with the deceased is
indicative of a need for treatment. Until recently, relinquishing the tie to the
deceased has been a major goal of grief therapy (see, e.g., Humphrey &
Zimpfer, 1996; Raphael & Nunn, 1988; Sanders, 1989).
During the past decade, this view has been called into question (see
Stroebe & Schut, 2005, for a review). Indeed, an increasing number of
researchers now believe that it is normal to maintain a continuing connection
to the deceased, and that such a connection may actually promote good
adjustment to the loss (Attig, 1996; Klass, Silverman, & Nickman, 1996;
Neimeyer, 1998; Shmotkin, 1999). Others have maintained that it is time
to move beyond the dichotomy of disengagement versus continuing
connection (Boerner & Heckhausen; 2003; Russac, Steighner, & Canto,
2002). For example, Boerner and Heckhausen (2003) conceptualized
adaptive bereavement as a process of transforming mental ties to the
deceased that involves features of both disengagement and continuing
connection. They further proposed that this process of transforming the
relationship occurs by substituting mental representations of the deceased
for the lost relationship. Some mental representations may simply reflect
experiences that are retrieved from memory (e.g., remembering what the
deceased said in a particular situation). Others may be newly constructed
by adding new aspects to ones preexisting image (e.g., imagining what
the deceased would say). Boerner and Heckhausen (2003) also noted that
different ways of transforming the relationship may be more or less adaptive
for a particular person. Stroebe and Schut (2005) extended this view by
arguing that certain types of continuing bonds, as well as certain types of
relinquishing bonds, can be helpful or harmful. Their notion of relinquishing
ties, however, is one of relocating rather than forgetting the deceased,
reflecting the idea of transforming the nature of the relationship to symbolic,
internalized, imagined levels of relatedness (Boerner & Heckhausen, 2003;
Shuchter & Zisook, 1993; Stroebe & Schut, 2005).
Historically, one of the first theorists to question the importance of breaking

down attachments was Bowlby (1980). In his later writings, Bowlby
maintained that continuing attachments to the deceased, such as sensing his
or her presence or talking with him or her, can provide an important sense
of continuity and facilitate adjustment to the loss. A similar view has been
expressed by Hagman (1995, 2001), who argued that there had been too
much emphasis on relinquishment of the bond with the deceased. In fact,
Hagman indicated that, in some cases, it is more adaptive to restructure
ones memories of the deceased so as to allow a continuing connection. In
their influential book, Continuing Bonds, Klass et al. (1996) also emphasized
the potential value of maintaining a connection with the deceased. These
investigators noted that their training led them to expect grief resolution to
be accompanied by breaking down attachments to the deceased. However,
this is not what they found in their research or in their clinical work. Instead,
their work indicated that most people experienced a continuing connection
with the deceased and that these connections provided solace, comfort, and
support, and eased the transition from the past to the future (p. xvii).
Just as it was previously maintained that breaking the bond between the
bereaved and deceased should be an important goal of therapy, many
clinicians now argue that such bonds should be facilitated as part of
bereavement counseling. Silverman and Nickman (1996) concluded that the
tie between the bereaved and the deceased loved one should be viewed
as a strengthening resource, and that it should be explicitly encouraged
in bereavement interventions. Along similar lines, Fleming and Robinson
(1991) have argued that it is important for the bereaved to confront such
questions as what he or she has learned from the deceased, and how
he or she has changed as a result of the relationship with the deceased.
Neimeyer (2000, 2001) has proposed a number of innovative methods for
developing an ongoing connection with the deceased, such as writing a
biographical sketch of the deceased or writing letters to the deceased along
with imaginary answers, which are to be written by the bereaved from the
deceased persons perspective. Other investigators have provided specific
suggestions about how to learn more about the deceased and his or her
possible influence on ones life. For example, Attig (2000) has indicated
that it can be helpful to explore records such as letters or diaries, as well as
sharing memories with others who knew the deceased. He has suggested
that the bereaved can benefit considerably by talking with people who may
have a different perspective on the deceased. For example, a wife might
seek out opportunities to talk with her deceased husbands coworkers,
or parents may make an effort to talk with the friends of their deceased
adolescent son.
Evidence for Prevalence and Types of Continuing Connections
Does empirical evidence support the view that continuing attachments to

the deceased are common, and that they facilitate good adjustment? Since
the 1970s, studies have appeared in the literature suggesting that many
forms of attachment to the deceased are common (see, e.g., Glick, Weiss,
& Parkes, 1974; Parkes & Weiss, 1983; Rees, 1971). The most frequently
studied forms of attachment include sensing the presence of the deceased,
seeing the deceased as protecting or watching over oneself, and talking to
the deceased (see Klass & Walter, 2001, for a review). For example, Zisook
and Shuchter (1993) found that 13 months after their spouses death, 63% of
the respondents indicated that they feel their spouse is with them at times,
47% indicated that he or she is watching out for them, and 34% reported
that they talk with their spouse regularly. Similar results have been reported
by Stroebe and Stroebe (1991), who found that 2 years following the death of
a spouse, a third of the bereaved still sensed the presence of the deceased.
Results suggesting a continuing connection between the deceased and the
bereaved have also been reported by Bonanno, Mihalecz, and LeJeune (1999)
in a study of the emotional themes that emerge during bereavement. These
investigators have reported that, 6 months after the loss, more than 80% of
the bereaved described emotional themes indicative of an enduring positive
bond. Similar findings were obtained by Richards, Acree, and Folkman (1999)
in their study of bereavement among caregivers of men who died of AIDS.
These investigators reported that 34 years post-loss, 70% of the bereaved
caregivers reported an ongoing inner relationship with their deceased
partner. Continuing ties with the deceased took many forms: some deceased
partners were thought to serve as guides, some were believed to be present
at times, and some talked with the bereaved partner. A sense of closeness
with the deceased persisted even though most of the men had made life
changes (e.g., changing jobs or living situations). As Richards et al. (1999)
have indicated, The continued relationship to the deceased did not appear
to be an aspect of clinging to the past but, rather, a part of a reorganized
present where the deceased assumed a new position in the living partners
world scheme (pp. 122123).
Data from the Harvard Child Bereavement Study (Silverman & Worden,
1992) indicate that it is common for children to maintain a connection with
deceased parents. Silverman and Nickman (1996) reported that 4 months
after losing a parent, 74% of the children had located their parent in heaven,
and most viewed the parent as watching out for them. Moreover, nearly
60% of the children reported that they talked with the deceased parent,
and 43% indicated that they received an answer. A year following the loss,
these attachment behaviors were still very prevalent, with nearly 40% of the
children indicating that they talked with their deceased parent.
There has also been interest in connections in which the deceased loved one
serves as a moral compass or guide (see, e.g., Klass & Walter, 2001; Marwit
& Klass, 1996). Although this form of continuing bond has received less study
than those mentioned earlier, Glick, Weiss, and Parkes (1974) found that at 1
year following the loss, 69% of those who lost a spouse expressed agreement
with the statement that they try to behave as the deceased would want them
to. Similarly, Stroebe and Stroebe (1991) found that at 2 years following the
death of their spouse, half of the respondents indicated that they consulted
the bereaved when they had to make a decision. Several similar kinds of
attachment behavior have been described in the literature, including relying
on the deceased as a role model, incorporating virtues of the deceased into
ones character, working to further the deceaseds interests or values, and
reflecting on the deceased persons life and/or death to clarify current values
or value conflicts (Marwit & Klass, 1996; Normand, Silverman, & Nickman,
1996).
In a related study, Field, Gal-Oz, and Bonanno (2003) assessed the frequency
of a wide variety of attachment behaviors. They included such items as
attempting to carry out the deceaseds wishes, having inner conversations
with the deceased, taking on the spouses values or interests, using the
spouse as a guide in making decisions, reminiscing with others about the
spouse, experiencing the spouse as continuing to live through oneself,
having fond memories of the spouse, and seeing the spouse as a loving
presence in ones life. The results indicated that most of these types of
connection were quite prevalent even at 5 years after the loss. On average,
participants endorsed these items in the range of moder ately true. Items
that received the highest scores included keeping things that belonged to
ones spouse, enjoying reminiscing with others about ones spouse, seeing
the spouse as a loving presence in ones life, expressing awareness of the
positive influence of ones spouse on who one is today, and having fond
memories of ones spouse. Items endorsed less frequently at 5 years post-
loss included seeking out things that remind one of the spouse, awareness of
taking on ones spouses values or interests, and having conversations with
ones spouse.
Continuing Connections and Adaptation
Although many studies have examined the prevalence of continuing

connections to the deceased among the bereaved, only a few have examined
the relationship between such connections and adaptation to the loss.
These studies have yielded inconclusive evidence. In studies assessing the
frequency of sensing the presence of the deceased or talking with him or
her, the majority of respondents experience these encounters as comforting
(Klass & Walter, 2001). Silverman and Nickman (1996) have also noted that
the ties that children developed with their deceased parents were apparently
beneficial. Many children made spontaneous comments such as It feels
good to think about him. In fact, when the children were asked what they
would advise another bereaved child to do, they gave answers such as Just
think of them as often as you can. However, as other investigators have
noted (cf. Fraley & Shaver, 1999), a significant number of survivors report
that ongoing connections are not always comforting. For example, nearly
60% of the children in the study by Silverman and Nickman (1996) indicated
that they were scared by the idea that their parents could watch them from
heaven. In fact, some children regarded their deceased parent as a ghost
whose presence was frightening and unpredictable (Normand, Silverman, &
Nickman, 1996). In a follow-up analysis of these data, Silverman, Baker, Cait,
and Boerner (2003) found that many of the children who showed emotional
and behavioral problems after the loss had a continuing bond with the
deceased that was primarily negative. These high-risk children carried
troubling legacies related to their deceased parents health, personality, or
role in the family. Health-related legacies, for example, reflected childrens
fear that they will die from the same condition or disease that killed their
parent. Role-related legacies reflected childrens sense that they needed to
assume the role in the family that was once filled by the parent, creating a
burden that was clearly too heavy for these children.
Datson and Marwit (1997) found that 60% of those who had lost a loved
one within the previous 4 years reported sensing the presence of their
deceased loved one at some point, and the vast majority (86%) regarded
the experience as comforting. However, those who reported that they had
sensed the presence of their loved one scored higher in neuroticism than
those who did not. These findings suggest that, in some cases, sensing the
presence of the deceased loved one may be more an indication of greater
distress than a sign of good adjustment.
In a study by Field, Nichols, Holen, and Horowitz (1999), interviewers rated

the extent to which bereaved individuals manifested four different kinds of
attachment behaviors 6 months after the loss. Those who tended to maintain
the deceased persons possessions as they were when he or she was alive,
or who tended to make excessive use of the deceaseds possessions for
comfort, exhibited more severe grief symptoms over the course of the 25-
month study. These respondents also showed less of a decrease in grief
symptoms over time. Attachment strategies that involved sensing the
deceased spouses presence, or seeking comfort through memories of their
loved one, were not related to the intensity of grief. These findings suggest
that whether continuing bonds are adaptive or maladaptive may depend on
the form that the connection takes.
To address this question, Field et al. (2003) conducted a follow-up study

on this same sample, in which they assessed a wide variety of attachment
behaviors at 5 years post-loss (see earlier discussion). Results showed that
each of the continuing bond items, as well as a composite score based
on all of the items that were assessed, was associated with more severe
grief as assessed 6 months after the death. There was a strong positive
correlation between continuing bonds assessed 5 years after the death and
grief assessed at the same time point. The relationship between continuing
bonds and other forms of well-being was much weaker, suggesting that the
relationship between continuing bonds and adjustment is largely restricted to
grief-related measures.
In another study, Field and Friedrichs (2004) examined the use of attachment
behaviors as a way of coping with the death of a husband. Fifteen early-
bereaved widows (4 months post-loss) and 15 later-bereaved widows (more
than 2 years) completed continuing bond and mood measures four times
each day for 14 consecutive days. Greater use of continuing bond coping
was related to more positive mood among the later- but not the early-
bereaved, and more negative mood in both groups. Furthermore, in time-
lagged analyses, greater use of continuing bond coping was predictive of a
shift toward more negative mood among early-bereaved but not among later-
bereaved widows. These findings suggest that continuing bond coping may
be less effective in mood regulation earlier than later on after the death. As
the authors noted, however, neither this nor the prior two studies allowed for
an investigation of the direction of causality between continuing bonds and
grief symptoms. Hence, it is not clear whether continuing bonds are simply
correlates of bereavement-related distress or whether the formation of such
bonds in fact plays a causal role in impending adjustment to bereavement.
In fact, it has been argued that the association between continuing bonds
and grief intensity is at least partially due to conceptual overlap between the
two constructs, and that this may have led to overestimating the strength
of this association (Schut, Stroebe, Boelen, & Zijkerveld, 2006). This group
of researchers conducted a prospective analysis of continuing bonds (712
months post-loss) and grief (9 months later; Boelen, Stroebe, Schut, and
Zijkerveld, 2006). In order to deal with the conceptual overlap between
continuing bonds and grief symptoms, they removed continuing bonds
like items from the grief scale. They found that maintaining bonds through
comforting memories, but not cherishing possessions of the deceased,
continued to predict later grief symptoms severity. Thus, when considered
together, the available studies demonstrate that continuing bonds should not
be regarded as exclusively adaptive.
In summary, our belief in the value of continuing attachments between

the bereaved and the deceased has shifted markedly over the past few
decades. Initially, it was believed that it was essential to break down ties
to the deceased. At present, such ties are widely regarded as normal and
generally beneficial. Because so few studies have examined the role such
ties may play in adjustment to loss, there is little evidence to support this
current view. In fact, the few studies that have explored the matter suggest
that continuing bonds are sometimes adaptive and sometimes maladaptive.
Future Directions
In future work, it will be important to learn more about whether certain

kinds of continuing bonds may facilitate good adjustment while others do
not. Some types of behaviors may in fact reflect the presence of continuing
bonds, whereas others may signal the presence of other psychological
processes. Maintaining the deceased persons possessions as they were,
for example, may reflect failure to accept the loss rather than a continuing
attachment to the deceased.
Results of the studies by Field et al. (1999, 2003) also suggest that whether
continuing bonds are adaptive may depend on how much time has elapsed
since the death. At this point, we do not know whether those who make
the best adjustments to a loss experience continuing bonds for several
years into the future, or whether these bonds gradually fade over time
as the bereaved become involved in other relationships and activities.
By examining a large and representative class of continuing bonds from
shortly after the loss through the next several years, it should be possible
to address critical questions about the possible causal role continuing bonds
may play in facilitating adjustment. Such questions could also be addressed
through experimental studies in which respondents are randomly assigned
to participate in exercises believed to promote continuing bonds, such as
discussions about what the deceased loved one has meant to them.
Even if continuing bonds are generally found to facilitate adjustment, it is

important to identify conditions under which this is not the case. Negative
legacies from past relationships can be related to aspects of the deceaseds
life (e.g., burdensome responsibilities that were once filled by the deceased,
such as caring for an elderly relative, that now fall on the bereaved), or to
aspects of the relationship with the deceased (e.g., if the relationship was
abusive or destructive in other ways). If the bereaved is left with such a
negative legacy, what kind of a connection to the deceased, if any, should
the bereaved attempt to develop? In some cases, perhaps reviewing the
relationship, and the negative legacy that is attached to this relationship,
can help the bereaved to attain important self-knowledge. However, it may
be this self-knowledge (e.g., I deserved to be with someone who treated me
better), rather than a positive tie with the deceased, that is helpful to the
person under such conditions.
In the process of clarifying the relationship between various continuing bonds

and adjustment, it would be valuable to have a greater understanding about
how particular sorts of connections are experienced and perceived by the
bereaved. For example, although it is common for the bereaved to talk with
the deceased and to report that this is comforting, little is known about what
transpires in such conversations or what psychological needs they may fulfill.
It will also be important to determine whether circumstances exist that might
impede or facilitate the development of continuing bonds that facilitate
adjustment. For example, the opportunity to talk with others who knew and
valued the deceased may help to facilitate the development of such bonds.
It may be more difficult for the bereaved to develop such bonds following
particular kinds of losses, such as a loss that cannot be acknowledged
or shared (Boerner & Heckhausen, 2003). Finally, future research should
address not only the conditions under which continuing bonds are beneficial,
but also try to identify conditions under which the relinquishment of such
bonds may promote better adjustment to bereavement (see Field, Gao, &
Paderna, 2005; Stroebe & Schut, 2005).
Expectations About Recovery
Description
Traditionally, it has been believed that once people have completed the
process of working through the loss and relinquishing their ties to
the deceased, they will reach a state of recovery. Most prior work has
conceptualized recovery in terms of a return to prebereavement or baseline
levels of psychological distress. As Weiss (1993) has emphasized, however, it
is important to examine a broader set of indicators when trying to determine
whether a person has recovered from a loss. These include freedom from
intrusive or disturbing thoughts and the ability to encounter reminders
without intense pain; the ability to give energy to everyday life; the ability
to experience pleasure when desirable, hoped-for or enriching events occur;
hopefulness about the future and being able to make and carry out future
plans; and the ability to function well in social roles such as spouse, parent,
and member of the community.
In the past, bereavement has been viewed as a time-limited process, with

people resuming normal life once they reach the end point (Malkinson,
2001). It was sometimes assumed that grief work would be completed
in approximately 12 months (Malkinson, 2001; Wortman & Silver, 2001),
although most discussions of recovery did not include a specific time
frame. Those who failed to recover after an appropriate amount of time
were often viewed as displaying chronic grief (see, e.g., Jacobs, 1993), a
pattern of grieving that has been regarded as an indication of pathological
mourning (Middleton et al., 1993). Over the past decade, however, this view
of the recovery process has begun to change. Malkinson (2001) has noted
that at this point, the 12-month time period is viewed as mythological and
that there is wide recognition that the process can take far longer.
Moreover, recovery is no longer viewed as a process with a discrete end

point. As widows and widowers sometimes express it, You dont get over it,
you get used to it (Weiss, 1993, p. 277). Several investigators have pointed
out that terms like resolution and recovery are becoming unpopular, and that
they are not applicable to most losses because they imply a once-and-for-all
closure that does not occur (see, e.g., Klass, Silverman, & Nickman, 1996;
Rando, 1993; Stroebe, Hansson et al., 2001; Weiss, 1993). Similarly, there is
a growing consensus that bereaved individuals may never return to their pre-
loss state. Weiss (1993) has argued that a major loss will almost invariably
produce changes in a persons character. Miller and Omarzu (1998) have
suggested that returning to ones pre-loss state may not be an optimal goal.
As Malkinson (2001) has expressed it, recovery can be a lifelong process of
struggling to find the balance between what was and what is (p. 675).
Evidence for Chronicity
Empirical evidence suggests that while most bereaved individuals do not

seem to experience intense distress for extended periods of time (see the
earlier section on the expectation of intense distress), a significant minority
of people develop long-term difficulties. This was found in the longitudinal
studies mentioned previously that included several post-loss time points
and provided evidence for different patterns of grief. Chronic grief, which
involved scoring consistently high in distress at post-loss time points, was
found among 30% of participants in the study on the loss of a child from SIDS
(Wortman & Silver, 1987), and anywhere between 8% and 26% in studies
on conjugal loss (24% in Bonanno et al., 1995; 13% in Bournstein et al.,
1973; 8% in Lund et al., 1986; 26% in Vachon, Rogers et al., 1982; and 20%
in Zisook & Shuchter, 1986). Recent caregiving studies have found similar
percentages for the chronic grief trajectory among bereaved caregivers
(ranging from 8% to 17%; e.g., Aneshensel et al., 2004; Zhang et al., 2008).
It should be noted that the highest percentage of respondents showing a
pattern of consistently high levels of distress following the loss came from
the study on death of a child to SIDS (Wortman & Silver, 1987). Another
important consideration is the striking difference among the studies on
conjugal loss in the percentage of respondents evidencing chronic grief.
This may be related to differences in the age of the respondents, and hence
the untimeliness of the loss. For example, the study by Lund et al. (1986)
focused on elderly bereaved, whereas the study by Vachon, Rogers, et al.
(1982) focused on loss of a spouse at midlife.
In our prospective work on conjugal loss (Bonanno et al., 2002), the

availability of pre-loss data made it possible to further distinguish a
chronic grief pattern, in which respondents scored low before the loss and
consistently high afterward (16%), from chronic depression (8%), which
involved scoring high prior to the loss and at all post-loss time points.
To further elucidate the nature of these patterns, Bonanno et al. (2002)
identified their pre-loss predictors. Chronic grievers were likely to have
had healthy spouses, to rate their marriage positively, and to show high
levels of pre-loss dependency (e.g., agreeing that no one could take the
spouses place). The chronically depressed group was less positive about
their marriage than were chronic grievers, but as dependent on their spouse.
Further analyses examined the context and processing of the loss at 6 and
18 months post-loss (Bonanno et al., 2004). Results indicate that chronic
grief stems from an enduring struggle with cognitive and emotional distress
related to the loss, whereas chronic depression results more from enduring
emotional difficulties that are exacerbated by the loss. For example, at
6 months post-loss, chronic grievers were more likely to report current
yearning and emotional pangs, and they reported thinking and talking about
the deceased more often than did chronically depressed individuals.
Most classic grief theorists (e.g., Jacobs, 1993) discuss the notion of chronic
grief but fail to indicate how long it typically lasts and whether it abates
at some point. To address this issue, we conducted a follow-up analysis
investigating whether the chronic grievers and the chronically depressed
would remain distressed up to 48 months post-loss (Boerner et al., 2005).
Overall, the chronic grief group experienced an intense and prolonged
period of distress. Measures of outcome and processing the loss measures,
however, indicated a turn toward better adjustment by the 48-month
time point, which suggests that this group does not remain chronically
distressed as a result of the loss. In contrast, the chronically depressed
group clearly demonstrated long-term problems, with little indication of
improvement between 18 and 48 months. This group not only showed the
poorest adjustment 4 years after the loss but also struggled the most with
questions about meaning. These differential findings for the chronic grief and
chronic depression group underscore the need to further refine the criteria
that are used to identify those who are at risk for long-term problems.
Risk Factors
Over the past decade, it has become increasingly clear that reactions to loss
are highly variable, but that a significant minority shows enduring effects.
Consequently, researchers have become interested in identifying factors that
may promote or impede successful adjustment to the death of a loved one.
Studying risk factors has the potential to advance bereavement theory by
helping to clarify the mechanisms through which loss influences subsequent
mental and physical health. Perhaps even more important, knowledge about
risk factors can aid in the identification of people who may benefit from
bereavement interventions.
Several broad classes of risk factors have been studied in the literature
(see Archer, 1999; Jordan & Neimeyer, 2003; and Stroebe & Schut, 2001;
Stroebe, Schut, & Stroebe, 2007, for reviews). These include demographic
factors, such as age, gender, and socioeconomic status; background factors,
including whether the respondent has a history of mental health problems
or substance abuse, or has experienced prior losses or traumas; factors
describing the type and nature of the relationship, such as whether it was
a child, spouse, or sibling who was lost and whether the relationship was
emotionally close or conflictual; personal and social resources, including
personality traits, attachment history, religiosity, and social support; and
the context in which the loss occurs, which refers to the circumstances
surrounding the death, whether the surviving loved one was involved
in caregiving, the type and quality of the death, and the presence of
concomitant stressors such as ill health of the surviving loved one. A
comprehensive review of these risk factors is beyond the scope of this
chapter. However, in this section, we wish to highlight selected areas
of research on risk factors that we believe are of emerging interest and
importance.
Most of the research on gender differences following the loss of a loved

one has focused on the loss of a spouse. There is clear evidence that, in
comparison to married controls, widowed men are more likely to become
depressed and to experience greater mortality than are widowed women
(see Stroebe et al., 2007, and Miller & Wortman, 2002, for reviews).
Interestingly, such deaths are especially likely among younger bereaved
men. Major causes of death among bereaved men include alcohol-related
illness, accidents and violence, suicide, and chronic ischemic heart disease.
One possible explanation for these gender differences is that men may
benefit more from marriage than do women, and may therefore be more
adversely affected when the marriage ends. Consistent with this view,
several studies have shown that women typically have many more close
social relationships than men, who rely primarily on their wives for support.
In addition, women usually perform more housework and child care than do
men. Because men often rely on their wives in these domains, they may find
it difficult to handle these matters on their own. However, research suggests
that, although social ties and household responsibilities are related to gender
differences following conjugal loss, they account for relatively little variance
in the relationship between widowhood and mortality or depression (Miller &
Wortman, 2002).
A second mechanism that may account for gender differences has been
suggested by Umberson (1987, 1992), who has demonstrated that women
typically take greater responsibility for their partners health care, diet,
nutrition, and exercise than do men. For example, married women are
typically the ones who schedule doctor appointments and regular checkups
for themselves and their spouses. They are also more likely to monitor
whether their husbands are taking prescribed medications, and to offer
reminders if necessary. Married women are also more likely to place
constraints on negative health behavior, such as drinking and driving.
Umberson concludes that the poor health of men following the death of their
spouse is caused in part by the loss of this positive influence on their health
behavior.
Studies of child loss have consistently found that mothers experience more
distress than do fathers. Available research indicates that this is the case
following perinatal death, death in infancy or childhood, and the death of
older children (see Archer, 1999, for a review). Women also show higher
distress than men following several different kinds of child loss. Dyregrov
and her associates (2003) conducted a study of the predictors of grief among
parents who lost a child through suicide, accidents, or SIDS. Across all three
samples, mothers evidenced higher levels of posttraumatic reactions and
complicated mourning than fathers. Mothers also experienced more intrusive
thoughts, bodily symptoms, depression, anxiety, and grief than did fathers.
Gender differences among parents who suffered different kinds of loss also
emerged in a study conducted by Murphy and her associates (Murphy,
Chung, & Johnson, 2002; Murphy, Das Gupta et al., 1999; Murphy, Johnson,
Chung, & Beaton, 2003; Murphy, Johnson, & Wu, 2003). Parents who lost
a child as a result of an accident, suicide, or homicide were interviewed
at several points in time following the death. These investigators found
significant gender differences on many indices of mental distress, including
depression, anxiety, somatic complaints, and cognitive functioning. In each
case, mothers scored higher than fathers. Women continued to show greater
overall distress than men as the study continued. In fact, gender was one
of the best predictors of changes in distress over time. Mental distress of
fathers showed a greater decline over time than the mental distress of
mothers (Murphy, Chung, & Johnson, 2002).
Available research suggests that gender differences also exist in the coping
strategies that are most helpful in dealing with the death of a spouse or child
(see Archer, 1999, for a review). In a treatment study conducted by Schut
et al., for example, widows showed a greater decline in distress following
counseling that focused on day-to-day problems. In contrast, widowers
showed a greater decline following counseling that facilitated emotional
expression. According to Archer, such findings reflect a sociocultural pattern
of gender differences involving the inhibition of emotional expression by
boys and men. A similar pattern of findings emerged from studies on how
parents cope with the death of a child. Mothers typically deal with such a
loss by seeking support or by communicating with other family members.
In contrast, fathers attempt to conceal their feelings, which they claim is
to protect their wives. Interestingly, wives often tend to complain that their
husbands are not willing to share their feelings (see Archer, 1999 for a more
detailed discussion).
Murphy, Das Gupta et al. (1999) report findings consistent with this view.
Their results showed an interesting shift in the symptom patterns for fathers
and mothers starting in the second year of the study. At that point, mothers
symptoms declined. Fathers, who started out with lower distress than their
wives, reported slight increases in five of the ten symptoms that were
assessed. This suggests that, consistent with Archers (1999) analysis, men
may hold in their grief initially in an effort to be strong for their families
(Martin & Doka, 2000). According to Archer (1999), such finding can be seen
as part of a widespread pattern of male inexpressiveness (p. 245).
Virtually all of the studies that have examined how bereavement is affected
by the nature of the relationship have focused on the loss of a spouse.
Historically, clinical writings on loss have maintained that chronic grief
results from conflict in the marital relationship or feelings of ambivalence
toward the spouse (see, e.g., Bowlby, 1980; Freud, 1917/1957; Parkes &
Weiss, 1983). However, well-controlled studies fail to provide support for
this view (Bonanno et al., 2002; Carr et al., 2000). Clinicians have also
maintained that excessive dependency on ones spouse is a risk factor
for chronic grief (see, e.g., Lopata, 1979; Parkes & Weiss, 1983). Available
evidence suggests that this is indeed the case. In the Bonanno et al. (2002)
study described earlier, chronic grievers showed significantly higher levels of
dependency on their spouse, as well as of general interpersonal dependency
than did respondents in some of the other trajectory groups. It would
be interesting to determine whether the nature of the relationship is an
important risk factor in other kinds of relationships. For example, do parents
have more difficulty resolving their grief following the death of an adolescent
child if the relationship was conflictual?
Regarding personal and social resources, some of the most important

work linking personality with bereavement outcome has been conducted
by Nolen-Hoeksema and her colleagues (see, e.g., Nolen-Hoeksema &
Larson, 1999; Nolen-Hoeksema, 2001). In a study on coping with conjugal
loss, she identified two personality variables that played an important
role: dispositional optimism and a ruminative coping style. Those who
scored high on dispositional optimism (i.e., the tendency to be optimistic in
most circumstances) showed a greater decline in symptoms of depression
following the loss and were also more likely to find meaning or benefit in the
loss than were pessimists. As mentioned earlier, a ruminative coping style
involves a tendency to engage in thoughts and behaviors that maintain
ones focus on ones negative emotions and the possible causes and
consequences of those emotions (Nolen-Hoeksema, 2001, p. 546). Nolen-
Hoeksemas findings indicate that those who engage in rumination following
loss show little decrease in distress over time. Although bereaved ruminators
believed that focusing on the loss would solve their problems, this was not
the case: They were significantly less likely to become actively engaged in
effective problem solving than were nonruminators.
Several studies have provided evidence that the loss of a child leads to more
intense and prolonged distress than any other type of loss (Cleiren, 1993;
Cleiren, Diekstra, Kerhof, & van der Wal, 1994; Nolen-Hoeksema & Larson,
1999). In an important study comparing the loss of a child, spouse, sibling,
or parent, Cleiren et al. (1994) found that the kinship relationship influenced
virtually all aspects of functioning after the loss, with mothers most strongly
affected, followed by widowers and sisters. Sisters is a group that heretofore
had not been identified as vulnerable.
In recent years, there has been increasing interest in the role that religious
or spiritual beliefs may play in dealing with a loved ones death (see Stroebe,
Hansson, Schut, Stroebe, & Van den Blink, 2008, for a more detailed
discussion). Many investigators have suggested that religious beliefs
may ease the sting of death and facilitate finding meaning in the loss, by
providing a ready framework of beliefs for incorporating negative events
(Pargament & Park, 1995). It has also been argued that specific tenets of
ones faith, such as the belief that the deceased is in a better place, or that
the survivor and deceased will be reunited in the afterlife, may mitigate the
distress associated with the death of a loved one. Unfortunately, most of
the studies that have examined variables of this sort are methodologically
weak, and the results are conflictual. However, there are indications in the
literature that religious beliefs facilitate finding meaning in the death of a
child (McIntosh, Silver, & Wortman, 1993; Murphy, Johnson, & Lohan, 2003).
Moreover, available evidence suggests that those with spiritual beliefs are
more likely to use positive reappraisal and effective problem solving than
are those who do not hold such beliefs (Richards et al., 1999; Richards &
Folkman, 1997).
As noted earlier, there is also a great deal of interest in the relationship

between a persons attachment style and his or her reaction to the loss of a
loved one (see Shaver & Tancredy, 2001; Stroebe, Schut, & Stroebe, 2005a;
Zhang et al., 2006, for a more detailed discussion). For example, Shaver and
Tancredy (2001) have maintained that individuals with a secure attachment
style find it easy to be close to others, and typically react to loss with normal
but not overwhelming grief. Those with an insecure-dismissing orientation
to relationships have difficulty trusting others or allowing themselves to
depend on others, and are compulsively independent (Stroebe, Schut,
& Stroebe, 2005a). These individuals would be expended to suppress and
avoid attachment-related emotions, and to show relatively little distress
following a major loss. Those with an anxious or preoccupied orientation
to relationships have a strong desire to be close to others but are often
preoccupied or worried that their partner will abandon them. Such individuals
would be expected to react to the loss with intense distress and to remain
upset and preoccupied with the loss. Although few studies have tested these
hypotheses, some limited evidence suggests that attachment style may be
important. For example, Wayment and Vierthaler (2002) found that persons
with a secure attachment style showed lower levels of depressive symptoms
following the loss of a loved one than did those with a preoccupied style, who
expressed more distress and were more likely to engage in rumination.
At present, some of the most exciting work on risk factors has focused on
various factors associated with the context in which the death occurs. One
contextual factor that is generating increasing research interest concerns the
circumstances surrounding the loss. Accumulating evidence clearly suggests
that grief is more likely to be intense and prolonged following the sudden,
traumatic loss of a spouse or child.
In an early study examining the effects of losing a spouse or child in a motor

vehicle crash 47 years previously (Lehman, Wortman, & Williams, 1987),
comparisons between bereaved and control respondents, matched on a
case-by-case basis, revealed significant differences on depression and other
psychiatric symptoms, role functioning, and quality of life. The bereaved
experienced more strain in dealing with surviving children and family
members, and felt more vulnerable to future negative events. Bereavement
was associated with an increased mortality rate, a decline in financial status,
and, in the case of bereaved parents, a higher divorce rate. A majority of
respondents indicated that they were still experiencing painful thoughts and
memories about their loved one.
Another study focusing on how parents are affected by the sudden, traumatic
loss of a child (Murphy et al., 2002) found that 5 years post-loss, 61% of
mothers and 62% of fathers met diagnostic criteria for mental distress. The
findings demonstrated that 28% of the mothers met diagnostic criteria for
PTSD, which was nearly three times higher than the rate for a normative
sample. For fathers, 12.5% met the diagnostic criteria for PTSD. This was
two times higher than the rate for men in the normative sample. In a follow-
up study, Murphy, Johnson, Wu, et al. (2003) examined the influence of
type of death (accident, suicide, homicide) and time since death on parent
outcome. Those who lost a child through homicide were more likely to
manifest symptoms of PTSD. However, a majority of parents reported that
it took them 3 or 4 years to put the loss into perspective and continue with
their lives, and this assessment was not affected by the childs cause of
death.
Similar results were obtained in a study by Dyregrov et al. (2003), who

focused on parents who lost a child as a result of suicide, SIDS, or an
accident. The results showed that 1.5 years after the death of their child,
a considerable proportion of parents showed symptoms of PTSD and
complicated grief (CG) reactions. Rates of problems were highest for those
who lost loved ones through accidents or suicide. As many as 78% of these
parents were above the risk zone of maladaptive symptoms of loss and
long-term dysfunction (p. 155). On the basis of these findings, the authors
concluded that to lose a child suddenly and in traumatic circumstances
is a devastating experience for the survivors, most often resulting in a
tremendous and long-lasting impact (p. 156).
Available evidence also suggests that the sudden, traumatic death of

a spouse is associated with intense and prolonged distress. In addition
to the aforementioned study by Lehman et al., two more recent studies
help to clarify the impact of such losses. Zisook, Chentsova-Dutton, and
Shuchter (1998) followed a large number of respondents longitudinally
for the first 2 years after losing a spouse. Those whose spouse died as a
result of an accident, homicide, or suicide were more likely to develop PTSD
symptoms than were those who experienced a sudden, unexpected death
due to natural causes (e.g., heart attack). Those who scored high on PTSD
symptoms also scored high on depression. Similarly, Kaltman and Bonanno
(2003) compared respondents whose spouses died of natural causes with
those who experienced the death of a spouse as a result of an accident,
homicide, or suicide. The latter group manifested a significantly higher
number of PTSD symptoms as long as 25 months after the loss. Moreover,
those who lost a loved one through natural causes showed a decline in
depressive symptoms, whereas those who lost a loved one as a result of
an accident or suicide showed no drop in depressive symptoms over the 2-
year course of the study. Among the natural death cohort, there were no
significant differences in PTSD symptoms or the persistence of depression
between bereaved individuals who had sudden, unexpected losses and those
who had expected losses.
Taken together, these studies provide compelling evidence that the death
of a spouse or child under traumatic or violent circumstances is linked to
more intense and prolonged grief. It is important to note that such deaths are
associated with PTSD symptoms, as well as with symptoms of depression.
This means that, in addition to dealing with such symptoms as yearning for
the deceased and profound sadness, survivors of sudden, traumatic losses
must contend with such symptoms as intrusive thoughts and flashbacks,
feelings of detachment or estrangement, irritability, and problems in
concentration.
The studies reviewed here have focused primarily on the untimely death of
a spouse or child. Do the circumstances under which the death occurs have
an impact on survivors when a loved one dies following a life-threatening
illness or when an elderly person dies? For people aged 65 and older, chronic
illnesses such as cancer, heart disease, and diabetes account for more
than 60% of all deaths. Over the past decade, a great deal of research has
focused on the impact of caregiving (see Schulz, Boerner, & Hebert, 2008,
for a review). Studies have shown that caregivers are more stressed and
depressed and have lower levels of well-being than noncaregivers (Pinquart
& Sorensen, 2003a, 2003b). Depressive symptoms increase as the number of
hours one engages in caregiving increases (Schulz et al., 2001).
In recent years, investigators have begun to examine the impact of

caregiving on adjustment to the loss following the loved ones death.
This research demonstrates that the relationship between caregiving and
adjustment to bereavement is complex. Although stressful caregiving is
associated with poor psychological adjustment when the spouse is alive,
many overly taxed caregivers seem to rebound to relatively high levels
of functioning after the death (Schulz et al., 2003). However, a minority
of strained caregivers demonstrated intense and prolonged grief, and
investigators are attempting to uncover the determinants of this reaction.
Thus far, research indicates that high levels of caregiving burden, feeling
exhausted and overloaded, and lack of support (Gross, 2007; Hebert et al.,
2006) put caregivers at risk for more intense and prolonged grief reactions.
Research with dementia caregivers found that among the caregivers with
poor adjustment were not only those who were in difficult caregiving
situations (e.g., caring for a more cognitively impaired patient), but also
some who reported very positive features of the caregiving experience
(Boerner et al., 2004; Schulz et al., 2006). This intriguing finding suggests
that there may be some positive caregiving experiences that can also put a
person at risk for difficulties following the loved ones death. This may be the
result of two related factors: losing their loved one deprives these individuals
of a meaningful and important role, and a positive view of caregiving may
be a reflection of an extremely close relationship between caregiver and the
person they cared for.
Another aspect of the caregiving situation that has emerged as a potential

risk factor is preparedness for the death. Although the research on this issue
is only in its infancy, it seems clear that, despite providing high-intensity
care, often for years, many bereaved caregivers perceive themselves as
unprepared for the death. Those who have such feelings tend to deal with
more complications in their grieving process (Hebert et al., 2006). However,
we need to gain a better understanding of what it means to be prepared
for a loved ones death. Based on a series of focus groups with caregivers,
Hebert and colleagues proposed that preparedness has emotional (e.g.,
being at peace with prospect of death), pragmatic (e.g., having funeral
arrangements planned), and informational (e.g., medical aspects of end-
of-life) components (Hebert et al., 2009). This study also showed that, for
example, a person could feel prepared with respect to the informational and
pragmatic components, but yet feel entirely unprepared emotionally. Overall,
this work suggests that even the relatively certain prospect of death does not
necessarily translate into being prepared for what lies ahead, and that this
might be an important area for professionals to address in their encounters
with caregivers, before and after the loss.
An important issue that is discussed primarily in the context of caregiving for

terminally ill patients is how to help a dying person to experience a good
death. According to Carr (2003), a good death is characterized by physical
comfort, support from ones loved ones, acceptance, and appropriate
medical care. Carr is one of the first bereavement researchers to suggest
that whether a loved one dies a good death may have implications for
the grief experienced by surviving family members. In analyses based on
the Changing Lives of Older Couples (CLOC) data, she found that those who
reported that their spouses were in severe pain showed elevated levels
of yearning, anxiety, and intrusive thoughts following the loss. Those who
believed that their spouses medical care was negligent reported elevated
anger symptoms.
Several studies have shown that unique stresses are associated with caring
for a loved one who is dying (see Carr et al., 2006, for a more detailed
discussion). For example, Prigerson and her associates (2003) examined
quality of life among hospice-based dying patients and their caregivers, who
included spouses and children. The caregivers had cared for their relatives
for 2 years, on average, prior to the hospice admission. More than three-
quarters of the caregivers reported that they had witnessed the patient in
severe pain or discomfort, and 62% said they had witnessed this daily. Nearly
half reported that their loved one was unable to sleep or unable to eat or
swallow on a daily basis. These findings are particularly striking when one
considers that one of the core goals of hospice care is pain management.
Several studies have shown that family members report more positive
evaluations of their spouses quality of care at the end of life and better
psychological adjustment following the death when their loved one spent his
or her final weeks using in-home hospice services rather than receiving care
in nursing homes, hospitals, or at home with home health nursing services
(see, e.g., Teno, Clarridge, & Casey, 2004). In fact, a study by Christakis
and Iwashyna (2003) indicates that hospice use can reduce the increased
mortality risk associated with bereavement. These investigators conducted
a matched cohort study with a sample of nearly 200,000 respondents in
the United States. At 18 months after the loss, significantly fewer deaths
occurred among wives whose husbands had received hospice care than
among those whose husbands received other types of care (typically a
combination of home care with occasional hospital stays). Mortality was
also lower for husbands whose wives received hospice care, but the effect
fell short of statistical significance. These studies suggest that in-home
hospice care may be more conducive to a good death for the patient and,
consequently, his or her surviving loved ones.
Complicated Grief as A Distinct Psychiatric Disorder
Despite the progress that has been made in identifying risk factors
for chronic grief, there are no standard guidelines to determine how
complications following bereavement should be diagnosed and when they
should be treated. Among theorists as well as clinicians, there has been
a long-standing awareness that bereavement can result in psychiatric
problems. As Jacobs (1993) has indicated, most research has focused on the
prevalence of clinically significant depression and anxiety disorders among
the bereaved. More recently, as was described earlier, researchers have
become interested in the prevalence of PTSD following the loss of a loved
one, particularly among survivors of sudden, traumatic losses.
In an important new line of research, Prigerson and her associates (e.g.,

Prigerson, 2004; Jacobs, Mazure, & Prigerson, 2000; see Lichtenthal, Cruess,
& Prigerson, 2004; Prigerson, Vanderwerker, & Maciejewski, 2008; Zhang, El-
Jawahri, & Prigerson, 2006, for a review) have focused on the development of
diagnostic criteria to identify those individuals who exhibit chronic grief and
who would benefit from clinical intervention. Drawing from epidemiological,
pharmacological, and clinical case studies, these investigators have
identified a unique pattern of symptoms called complicated grief.1 They
have maintained that these symptoms are associated with enduring mental
and physical health problems that are typically slow to resolve and that can
persist for years if left untreated. To obtain a diagnosis of CG, individuals
must experience intense yearning for the deceased daily or to a disabling
degree. They must also experience five or more additional symptoms during
the past month: feeling stunned, dazed or shocked by the death; trouble
accepting the death; difficulty trusting others; excessive bitterness or
anger related to the loss; feeling uneasy about moving forward; feeling that
life is empty and holds no meaning without the deceased; and numbness
(absence of emotion) since the loss. These symptoms must cause marked
and persistent dysfunction in social, occupational, or other important roles,
and the symptom disturbance must last at least 6 months. Research has
shown that these symptoms form a unified cluster and that they are distinct
from depression, anxiety, or PTSD. For example, feeling sad and blue is
characteristic of depression but not of CG, and avoidance and hyperarousal
are characteristic of PTSD but not of CG. Unlike these other disorders,
vulnerability to CG is believed to be rooted in insecure attachment styles that
are developed in childhood. Consistent with this notion, evidence has shown
that childhood abuse and serious neglect are significantly associated with CG
during widowhood (Silverman, Johnson, & Prigerson, 2001).
Evidence has shown that the prevalence of CG among individuals who have
lost a loved one is between 10% and 20%. The symptoms of CG typically last
for several years. They are predictive of morbidity (e.g., suicidal thoughts
and behaviors, incidence of cardiac events, high blood pressure), adverse
health behaviors (e.g., increased alcohol consumption and use of tobacco),
and impairments in the quality of life (e.g., loss of energy). Interestingly,
bereaved people with CG are significantly less likely to visit a mental health
or physical health care professional than those without grief complications.
People with severe mental anguish may have difficulty mobilizing themselves
to go into treatment. They may also avoid treatment because they believe it
would be unbearably painful to focus on the loss.
Future Directions
We now know that a significant minority of individuals experience enduring

difficulties following the loss of a loved one, and we have a reasonably good
understanding of the risk factors for grief complications. However, important
questions remain unanswered about exactly how people do recover from
a loss. As Archer (1999) has observed, It is commonly believed that it is
not time itself that is the healer but some process which occurs during this
time (p. 108). At this point, however, there is considerable confusion about
what this process involves. It is now clear that some people recover from
a loss without working through the implications of what has happened.
But how do people come to accept the loss, to encounter reminders without
distress, and to become engaged in new interests or pursuits?
In evaluating the impact of a major loss, it is important to recognize
that the survivor may also be coping with additional losses. The death
of child, for example, may require surviving parents to face the loss of
their hopes and dreams for the future, the loss of their belief in God as a
benevolent protector, and the loss of their beliefs in their ability to control
important outcomes. The death of a spouse is often accompanied by
concurrent stressors, including loss of income or struggling with tasks
formerly performed by the deceased. Documenting the frequency of such
secondary losses (Rando, 1993) will help to clarify our understanding of the
bereavement experience and provide valuable information for intervention.
Although most research on the enduring effects of loss has focused on

mental and physical health problems, there is increasing recognition that
losses can bring about positive psychological changes (Tedeschi & Calhoun,
1996, 2004). Several researchers have documented, for example, that
following the loss of a spouse, the surviving spouse reports greater feelings
of self-confidence, a greater awareness of ones strengths, and a greater
inclination to try new experiences (see Wortman, 2004, for a review). It less
clear whether sudden, traumatic losses of a spouse or child are typically
accompanied by personal growth. There are some indications that survivors
of trauma resent the implication that they should be able to find something
good in what has happened, and that others exhortations to this effect often
heighten survivors feelings of inadequacy and shame (see Wortman, 2004,
for a more detailed discussion).
Conclusion
In previous papers, we have described several common assumptions about

coping with loss that appear to be held by professionals in the field as well
as by laypersons. We conducted a careful evaluation of each assumption
and concluded that most were not supported, and were often contradicted,
by the available data. Indeed, this is why these assumptions were originally
referred to as myths of coping with loss.
It has been 20 years since the first articles on the myths of coping appeared
in the literature (Wortman & Silver, 1987, 1989). As the scientific evidence
pertaining to these myths has continued to accumulate, there have been
some shifts in the prevailing views about how people cope with loss. The
main purpose of this chapter has been to summarize the most important
research bearing on the validity of each myth of coping, and also to
highlight how the myths themselves have changed over time.
Here, we first summarize how, in our judgment, these assumptions are
currently viewed by researchers. We then examine the extent to which the
myths of coping are still influential among practicing clinicians. We discuss
the relationship between belief in these myths and grief counseling and
therapy as it is currently practiced in the United States today. In particular,
we highlight extensive research evidence suggesting that treatment for grief
is in many cases not effective. We then consider the extent to which the
myths of coping continue to influence other health care providers who come
into contact with the bereaved, such as clergy and general practitioners.
Next, we consider the extent to which these myths of coping are maintained
by the bereaved themselves and their potential support providers. We also
explore whether these beliefs impact the amount and quality of support the
bereaved are likely to receive.
Implications for Research
Over time, it appears that researchers assumptions about the process

of coping with loss have changed in important ways. For example, most
researchers would probably agree that a large minority of respondents
fail to experience even mild depression following an important loss, that
delayed grief is rare, that positive emotions are common following a loss
and are associated with a good recovery, that not everyone may need to
actively confront their thoughts and feelings about the loss, that continuing
attachment to the loved one is normal, and that recovery from a loss is
highly variable and depends on many factors, including the nature of the
relationship and the circumstances surrounding the death.
Awareness of this body of work is leading researchers to ask new and

important questions about the process of coping with loss. As was noted
earlier, for example, many of the early studies on grief focused solely on
depression and other negative emotions and symptoms; questions about
positive emotions experienced during grieving were typically not included. At
this point, however, researchers not only are including measures of positive
emotions but also are attempting to identify the role that such emotions
may play in facilitating adjustment to a loss. In terms of outcome measures,
it has become clear that we must examine the possibility that losses can
bring about enduring positive changes, such as increased self-confidence and
independence, altered life priorities, and enhanced compassion for others
suffering similar losses (for a more detailed discussion of growth following
loss, see Wortman, 2004).
Despite these advances, it is important for researchers to ask themselves
whether they may hold assumptions or beliefs about the coping process that
are limiting the scope of their scientific inquiry into loss. In a collaborative
study called the Americans Changing Lives, for example (see Nesse,
Wortman, & House, 2006), personal interviews were conducted with a
national sample of people who had lost a spouse anywhere from 3 months
to 60 years previously. Several of the investigators wanted to eliminate
questions about widowhood for all respondents whose loss occurred longer
than 10 years ago, assuming that there would be no effects after that point.
Ultimately, the decision was made to ask these questions of all respondents.
This was fortunate because the results enhanced our knowledge about the
ways such losses continue to influence the surviving spouse. For example,
several decades after the loss, it was common for people to have thoughts
and conversations about their spouse that made them feel sad or upset (see
Carnelley, Wortman, Bolger, & Burke, 2006).
Implications for Treatment
Earlier, we have attempted to argue that, in most cases, researchers no

longer take the prevailing cultural assumptions about coping with loss at
face value and instead appear to recognize the extraordinary variability
in response to loss. It is less clear, however, whether the accumulation
of research findings has filtered down to clinicians or other health care
providers working with the bereaved, to potential support providers of the
bereaved, or to the bereaved themselves.
Clinicians
A review of books and articles written for and by clinicians indicates that
assumptions about the importance of going through a period of distress
and of working through the loss are still widely held. For example, in what is
perhaps the most widely used book on grief counseling written for clinicians
and other mental health professionals, Worden (2008) suggests that if
negative feelings are not expressed, psychological difficulties may emerge at
a later point.
Since the 1990s there has been a proliferation of grief counseling and
therapy. This is reflected in a wide variety of workshops, professional
conferences, and publications on the topic, as well as in countless individual
and group-based treatments offered in virtually all communities (Neimeyer,
2000). Most treatments for loss are based on the assumption that individuals
must work through their feelings to accommodate the loss (see, e.g.,
Rando, 1993; Worden, 2008). As Neimeyer (2000) has indicated, most people
assume that grief counseling is a firmly established, demonstrably effective
service, which, like psychotherapy in general, seems to have found a secure
niche in the health care field (p. 542). And indeed, most clinicians who treat
the bereaved believe that what they do is helpful and necessary (Jordan &
Neimeyer, 2003).
To date, however, available research has failed to provide evidence that

grief treatments are efficacious. During the past decade, several reviews of
grief and mourning treatment studies have appeared in the literature. Some
authors have published narrative reviews (e.g., Jordan & Neimeyer, 2003;
Larson & Hoyt, 2007; Schut & Stroebe, 2010; Schut, Stroebe, Van den Bout
& Terheggen, 2001). Others have conducted meta-analytic reviews of grief
and mourning treatment studies (e.g., Allumbough & Hoyt, 1999; Kato &
Mann, 1999; Fortner & Neimeyer, 1999; (summarized in Neimeyer, 2000)).
These reviews have focused on somewhat different sets of studies and have
employed a variety of analytic approaches. With one exception (Larson &
Hoyt, 2007), however, each of these reviews came to basically the same
conclusion: that the scientific basis for the efficacy of grief counseling is
weak.
Currier, Neimeyer, and Berman (2008) have recently published a meta-

analysis of grief treatment studies that is far more comprehensive than the
others and that uses state-of-the-art statistical procedures. Their analyses
demonstrated that interventions had a small effect when respondents were
assessed at post-treatment, but no discernible effect at follow-up, which
was, on average, about 36 weeks later. Currier et al. (2008) pointed out
that despite the absence of overall effects, there was considerable variation
in the impact of the grief treatments that were studied. They conducted
additional analyses in order to learn more about the conditions under which
grief and mourning treatments may be effective. One finding to emerge
from their analyses is that the benefits derived from treatment were strongly
influenced by respondents level of distress. If respondents were selected
because they had experienced a loss, without regard to their level of
distress, positive treatment effects were unlikely. In contrast, in those studies
focusing on participants who were experiencing high distress surrounding the
loss, the results showed a clear benefit at post-treatment and also at follow-
up. According to Currier et al. (2008), in those studies in which the target of
intervention was respondents who were manifesting significant distress as
a result of the loss, effect sizes (a measure of clinical relevance) compare
favorably with the positive outcomes shown for psychotherapy in general.
Jordan and Neimeyer (2003) have identified some additional factors that may
influence the findings from grief treatment studies. They have suggested
that some studies may have failed to find a robust positive effect for grief
counseling because the studies were small and there may not have been
enough statistical power to detect differences between groups. In other
studies, findings may not have emerged because the treatment offered did
not include enough sessions (most included 812 sessions). Alternatively,
the intervention may not have been offered at the most appropriate time.
Neimeyer (2000) found that interventions that were delivered shortly after
the death had significantly smaller effect sizes than those delivered at a
later time. Jordan and Neimeyer (2003) have suggested that there may be
a critical window of time (p. 774) when it is best to offer interventions,
perhaps 618 months after the loss, before problematic patterns of
adjustment have become entrenched (p. 774). These investigators also
emphasized that the types of counseling needed shortly after the loss
may differ from what is needed a year or more after the loss, noting that
investigators should try to customize the type of intervention to particular
points in the bereavement trajectory.
Taken together, these findings suggest that, in many cases, people may not
need therapy following a loved ones death, but that some subgroups are
likely to benefit substantially from treatment. It would be useful to develop
interventions that are designed specifically to address the problems of
mourners in high-risk categories, such as those who have already developed
CG. Shear and her associates (2005) have recently completed a randomized,
clinical trial comparing an intervention designed for people with CG to
a more standard treatment for depression (interpersonal therapy). The
multifaceted CG intervention draws from research on the treatment of PTSD.
For example, clients are given exercises to help them confront avoided
situations. In addition, they are asked to tell their story into a tape recorder
and to play it back during the week. The average length of treatment was 19
weeks. Although both treatments produced improvement in CG symptoms,
there was a higher response rate and a faster time to response in the CG
treatment. This treatment would appear to hold considerable promise for
people who are struggling with CG.
Perhaps the main implication of this work for practicing clinicians is that they
should not assume that one type of intervention will work best for everyone.
As Jordan and Neimeyer (2003) have emphasized, It is a truism that grief
is unique to each individual, yet this wisdom is rarely reflected in the design
and delivery of services to the bereaved (p. 782). They suggest that treating
clinicians focus more attention on such issues as whether the client has
experienced previous traumas or losses, as well as the clients personality
structure, coping style, and available support resources.
This work suggests that it is essential for program administrators to focus

their efforts on identifying high-risk mourners. This task could be facilitated
by the development of screening tools that make it possible to identify
people at risk for subsequent problems. As was described earlier, Prigerson
and her associates (2008) have developed an Inventory of Complicated Grief
(now called Prolonged Grief) that has predictive validity regarding those who
are likely to develop CG.
One consistent finding that has emerged from the intervention studies
reviewed here is that those who seek treatment are likely to show better
results from grief therapy than those who are recruited into a treatment
(see Stroebe, Schut, & Stroebe, 2005b, for a more detailed discussion). It is
not clear whether this occurs because those who seek treatment are more
likely to have serious problems and hence benefit more from the treatment,
or whether other important factors underlie this effect. However, as was
noted earlier, there is evidence to indicate that individuals with CG are
less likely to seek treatment than are those whose grief is not associated
with complications. This suggests that those most in need of help may be
least likely to seek and obtain it. At this point, little is known about what
percentage of high-risk mourners seek help. It would also be highly useful
to understand the reasons why high-risk mourners often do not seek help.
Clearly, it is important for administrators and policy makers to find ways of
reaching out to high-risk mourners who do not avail themselves of treatment.
Other Care Providers
Although research on help-seeking is limited, available research suggests

that only a small percentage of those who experience major mental health
problems following bereavement seek professional help (see Jacobs, 1993,
for a more detailed discussion). To the extent that they seek assistance at all,
bereaved individuals are far more likely to approach physicians, nurses, or
clergymen than they are to seek formal grief counseling or therapy. Hence,
it is important to ask whether these care providers may hold assumptions
about the grieving process that interfere with their ability to provide effective
help and support to the bereaved.
Evidence suggests that physicians and nurses do not receive much training
about grief, and an examination of commonly used textbooks suggests that
such books often perpetuate the myths of coping. For example, books written
for nurses and physicians frequently maintain that people go through stages
of emotional response as they come to terms with the loss, and that failure
to exhibit distress is indicative of a problem (see, e.g., Potter & Perry, 1997).
Clearly, it is important for care providers to recognize that, particularly with
certain kinds of loss, it is normative to exhibit little distress, and that this
may be indicative of resilience.
How much do physicians and clergy know about the risk factors associated
with complications of bereavement? Do they know, for example, that a large
percentage of parents who experience the sudden, traumatic loss of a child
experience high levels of symptoms for years after the loss? If they are not
aware of these findings, they may convey to bereaved parents that they
should be over the loss, thus contributing to the burden such parents are
already shouldering. In our experience, it is common for physicians and those
in the clergy to assume that prolonged grief is indicative of a weakness or
coping failure on the part of the bereaved. It is also important for physicians
and clergymen to have a good understanding of the symptomatology
that accompanies particular types of loss. For example, they could be
far more helpful to those who encounter sudden, traumatic losses if they
understand that such losses are often accompanied by posttraumatic stress
symptoms. Many studies have suggested that following the traumatic death
of a loved one, survivors are frightened by such symptoms as memory loss,
concentration problems, and intrusive thoughts or images of the deceased
(Dyregrov et al., 2003), Physicians and clergymen are in a unique position
to normalize disturbing symptoms among bereaved who are not receiving
grief therapy or treatment. Bereaved individuals are likely to benefit from
learning that their symptoms are understandable, given what they have been
through, and that they do not convey mental illness or coping failure.
Knowledge of risk factors would not only help to ensure that bereaved
people are treated more compassionately by their physicians and clergymen
but would also increase the likelihood that those who would benefit from
counseling are encouraged to seek help. At present, little is known about
how common it is for these care providers to make referrals, or whether they
are knowledgeable about how or where to refer bereaved people for grief
counseling.
Considering the impact of bereavement on mortality, particularly among

men who lose their spouses, it would also be prudent for clergy to
encourage these men to see their physicians. These men would benefit from
encouragement, from physicians as well as clergymen, to take other positive
steps to maintain their health. Clergymen may also be in a good position to
mobilize support for the bereaved, particularly for widowed men who may
have relied primarily on their wives for support and companionship.
The Bereaved and Their Support Providers
At present, what expectations or assumptions about the grieving process are

prevalent among laypersons? When a person experiences a loss, does he or
she expect to go through stages of grief, beginning with intense distress?
If intense distress is not experienced, is this a source of concern? How
knowledgeable are laypersons about the symptoms of grief, and how do they
judge and evaluate their own reactions? Do they believe that it is necessary
to work through the loss, and if so, what kinds of behaviors do they engage
in to facilitate this? Do they assess their progress according to a timetable
concerning when they think they should be recovered? Are laypersons aware
that symptoms are more intense and prolonged following certain kinds of
losses, or do they hold themselves up to unrealistically high standards and
judge themselves harshly if they are not able to move on within a year
or so? Given that most bereaved do not seek grief counseling or therapy,
where do they turn for assistance, and to what extent are they able to obtain
information and/or support that is beneficial? It is also important to ascertain
whether certain assumptions or beliefs about coping with loss are held by
members of the bereaved persons support network and, if so, whether these
facilitate or impede the receipt of effective support.
Unfortunately, few studies have focused on these questions, and at present

little is known about how the grief process is viewed by the bereaved or by
those in their support network. However, there are some indications in the
literature that many laypersons still believe in stages of emotional response.
Elison and McGonigle (2003) describe a case in which one woman asked her
therapist to do something to make her angry. When the therapist asked why
she should do so, the client replied, My neighbor told me that at this stage, I
should be angry, and Im not. Im afraid Im not doing this right (p. xxiii).
It also appears that laypersons have strong expectations that the bereaved
will go through a period of intense distress. Those who do not appear to
be showing enough distress may elicit judgmental reactions from others. A
person who fails to react with sufficient distress may also be thought to be
in denial, with friends conveying the sentiment that it hasnt hit her yet.
Elison and McGonigle (2003) have pointed out that in cases of deaths that
occur under suspicious circumstances, failure to show distress may be shown
as evidence as guilt. They maintained that the failure of John and Patty
Ramsey to show distress following the murder of their daughter, JonBenet,
convicted them in the court of public opinion.
In their insightful book Liberating Losses, Elison and McGonigle (2003)

describe several situations in which people feel relieved or liberated
following the loss of a loved one. For example, they note that it is common to
experience feelings of relief after a long period of caregiving. Such feelings
are also prevalent when a person has been involved in a relationship with
someone who has been a constant source of criticism, abuse, or oppression.
In these cases, the death may be viewed as a God given divorce (see also
Sanders, 1999). Elison and McGonigle (2003) note how outsiders comments
are often unhelpful. For example, a friend may say Its okay to cry, or You
must miss him terribly, thus making the survivor feel even more guilty
and conspicuous. Or, they may make comments like, I cant believe youre
getting rid of his things already, implying that the survivors reactions are
inappropriate.
Regarding expectations about recovery, some studies suggest that the

bereaved judge themselves harshly if they continue to show intense distress
beyond the first few months. A frequent complaint of the bereaved is that
others expect them to be recovered from the loss far sooner than they are.
There is also evidence that others attempt to encourage a prompt recovery
following the loss, and that the bereaved do not find this helpful (Ingram
et al., 2001; Lehman, Ellard, & Wortman, 1986). For example, following the
death of a spouse, friends might try to arouse the surviving spouses interest
in new activities or in the resumption of old hobbies or interests. It is also
common for others to bring up the topic of remarriage. Discussions of this
topic are often initiated within a few days or weeks of the spouses death.
Other kinds of responses that are frequently made by potential support

providers but that are not regarded as helpful by the bereaved include
attempts to block discussions about the loss or displays of feelings (e.g.,
Crying wont bring him back); minimization of the problem (e.g., You
had so many good years together); invoking a religious or philosophical
perspective (e.g., God needed him more than you did); giving advice
(e.g., You should consider getting a dog; theyre wonderful companions);
and identification with feelings (e.g., I know how you feelI lost my
second cousin). It is also common for those in the support network to ask
inappropriate questions. They may ask about such matters as how the death
occurred (e.g., Was he wearing a seat belt?); about financial matters (e.g.,
How are you going to spend all of that insurance money?); or about the
loved ones possessions (e.g., What are you going to do with his tools?).
Studies have shown that unsupportive social interactions account for a
significant amount of the variance in depression among the bereaved,
beyond the variance explained by the level of present grief (Ingram et al.,
2001). Such comments are more likely to be made by relatives or close
friends than they are among casual acquaintances of the survivor (see
Wortman, Wolff, & Bonanno, 2004, for a more detailed discussion).
What types of responses from support providers do the bereaved regard as

beneficial? Research indicates that they value the opportunity to talk with
others about their feelings when they elect to do so (Lehman et al., 1986;
Marwit & Carusa, 1998). In fact, there is evidence that if people want to talk
about the loss and are blocked from doing so, they become more depressed
over time (Lepore et al., 1996). The bereaved also find it helpful when
others convey a supportive presence (e.g., I am here for you) or express
concern (e.g., I care what happens to you). Tangible assistance, such as
help with errands or meals, is typically regarded as helpful. Finally, contact
with a similar other is judged to be very helpful. Unlike those who have not
experienced such a loss, they may have a more accurate understanding of
what the bereaved has been through. Contact with similar others can also
reassure the bereaved that their own feelings and behaviors are normal.
In our judgment, it would be beneficial for the bereaved themselves,

and their potential support providers, to have greater awareness of the
extraordinary variability in responses to loss. We believe that awareness of
the conditions under which the bereaved may fail to experience or exhibit
distress, or may experience grief that is more intense and prolonged than the
norm, would also have a positive impact. Hopefully, greater understanding
of the available research will result in treatment of the bereaved that is less
judgmental and more compassionate.
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Notes:
(1.) More recently, Prigerson and colleagues have referred to complicated

grief as prolonged grief disorder (Prigerson, Vanderwerker, & Maciejewski,
2008). However, since the term complicated grief is still more commonly
used in the literature, we choose to retain this terminology for the purpose of
clarity.

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The Oxford Handbook of Health Psychology

Print publication date: Sep 2012

Camille B. Wortman, Kathrin Boerner

Abstract and Keywords

This chapter reviews those developments in the field of bereavement that

Bereavement, grieving, grief, death, loss, coping

The death of a loved one is a ubiquitous human experience and is often

In our judgment, one of the most fascinating things about studying

Over the years, we carried out several systematic evaluations of common

Because these assumptions about the grieving process seemed to be firmly

Theories of Grief and Loss

Many different theoretical formulations have influenced the current

Classic Psychoanalytic View

Another theoretical framework that has been extremely influential is

Beyond Stage Models

As research has begun to accumulate, it has become clear that there is

More recent theoretical models, such as Neimeyers model of meaning

Stress And Coping Approach

Toward More Comprehensive Models of Bereavement

The dual-process model of coping with bereavement (Stroebe & Schut,

More recently, Stroebe, Folkman, and colleagues proposed an integrative

Revisiting the Myths Of Coping

Over the past decade, bereavement research has continued to become

The vast majority of bereavement studies have focused on the loss of a

The Expectation of Intense Distress

Several of the most influential theories in the area, such as classic

However, available evidence suggests that most practicing clinicians

Evidence for Intense Distress

The longitudinal studies identified here provide evidence regarding the

It should be noted that category labels such minimal or absent grief do

Studies With Assessment of Mild Depression

Fortunately, such measures have been included in a number of studies. For

Is it true that if the bereaved do not become depressed following a major

Thus, available evidence clearly indicates that the so-called normal

Given the prevalence of resilience or low distress following a loss, we need

Positive Emotions Are Typically Absent

In the 1980s, Wortman and her associates became interested in whether

Evidence for Positive Emotions Following Loss

Subsequent studies have corroborated that positive emotions are surprisingly

Revised Stress and Coping Model

Drawing on her research on caregivers of men who died of AIDS, Folkman

Broaden-And-Build Theory of Positive Emotions

In subsequent work, it will be important to learn more about how people

The Importance of Working Through the Loss

Among researchers as well as practitioners in the field of grief and loss,

However, an examination of the most influential books on grief therapy

Evidence on The Value Of Working Through

Confronting Versus Avoiding Loss

In a study of gay men who lost a partner to AIDS, Nolen-Hoeksema and

In another study comparing those who used avoidant versus more

Talking About Negative Feelings

A study by Bonanno and Keltner (1997) casts doubt on the value of

Writing About Negative Feelings

Stroebe et al. (2002) conducted two exceptionally well-designed studies to

To determine whether the emotional expression of grief may be beneficial

More recently, it has been argued that rumination represents a form of

In future work, it will be important to include separate assessments of

Breaking Down Attachments

According to the traditional view on grief, espoused by Freud (1917/1957)

Historically, one of the first theorists to question the importance of breaking

Evidence for Prevalence and Types of Continuing Connections

Does empirical evidence support the view that continuing attachments to

Continuing Connections and Adaptation

Although many studies have examined the prevalence of continuing

Wortman & Boerner Oxford Handbook of Health Psychology

Wortman & Boerner Oxford Handbook of Health Psychology